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GONORRHEA 

ITS DIAGNOSIS AND TREATMENT 



GONORRHEA 



ITS 



DIAGNOSIS AND TREATMENT 



BY 



FREDERICK BAUMANN, Ph. D., M. D. 

Professor of Genitourinary Surgery in the American Medical Missionary 

College, and Instructor in Dermatology and Venereal Diseases 

in the College of Physicians and Surgeons, Chicago. 



SECOND EDITION REVISED 
FIFTY-TWO ILLUSTRATIONS IN THE TEXT 




NEW YORK AND LONDON 

D. APPLETON AND COMPANY 
1910 






Copyright, 1907* 1910. by 
D. APPLETON AND COMPANY 



Printed at the Appleton Press 
New York, U. S. A, 



CCLA256492 



r* 



PREFACE. 

In the preparation of this work, the author has at- 
tempted to fulfill an oft-repeated wish of the students at- 
tending his clinic at the Medical Department of the 
University of Illinois to furnish them with a concise 
digest of the diagnosis and treatment of the gonor- 
rheal infections of the lower genitourinary tract. The 
writings of Oberlaender and Kollmann have been con- 
sulted extensively and every effort has been made to 
adhere to their teachings as closely as possible. 

F. BAUMANN. 

103 State Street, Chicago. 



CONTENTS. 



CHAPTER I. 

Pace 

Anatomy of the Urethra i 

The Intravesicular Portion 2 

The Prostatic Urethra 3 

The Membranous Urethra ......... 6 

The Cavernous Urethra 8 

CHAPTER II. 

Pathology of Gonorrhea 10 

The Gonococcus 10 

Acute Gonorrhea 14 

Chronic Gonorrhea 17 

CHAPTER III. 

Diagnosis of Gonorrhea 21 

Inspection and Palpation 21 

Instrumental Examination 24 

Urethroscopy 27 

CHAPTER IV. 

Varieties of Gonorrhea 42 

Soft Infiltrations 45 

Hard Infiltrations 50 

Hard Infiltrations of the First Degree .... 50 
Hard Infiltrations of the Second Degree . -54 

Hard Infiltrations of the Third Degree . . . . 57 

The Changes of the Epithelium 62 

vii 



viii CONTENTS. 

CHAPTER V. 

Page 

Prognosis of Acute and Chronic Gonorrhea ... 66 

CHAPTER VI. 

Instruments Used in the Treatment or Gonorrheal 

Infiltrations 70 

CHAPTER VII. 

Method of Introducing Instruments into the Ure- 
thra and Bladder • &7 

CHAPTER VIII. 

General Considerations of Treatment 92 

Medical Treatment 93 

Instrumental Treatment 103 

CHAPTER IX. 

Treatment of the Various Stages of Gonorrhea . . 107 

Acute Gonorrhea 107 

Chronic Gonorrhea 113 

The Soft Infiltrations 114 

The Hard Infiltrations 122 

Special Therapeutics of the Anterior Urethra . . . 130 
Special Therapeutics of the Posterior Urethra . . .137 
Treatment of Hard Infiltrations of the Third Degree . 141 
Papillomatous Urethritis 152 

CHAPTER X. 

Bacteriuria and Non-gonorrheal Urethritis . . .155 
Chronic Non-gonorrheal Urethritis 155 

CHAPTER XI. 
Gonorrheal Prostatitis 157 



CONTENTS. ix 

CHAPTER XII. 

Page 

Gonorrheal Epididymitis 173 

Treatment 175 

CHAPTER XIII. 

Gonorrheal Inflammations of the Seminal Vesicles . 179 
Inflammations of Cowper's Gland 180 

CHAPTER XIV. 

Gonorrheal Urethritis in the Female 181 

Treatment 185 

CHAPTER XV. 
Gonorrheal Metastasis 188 

CHAPTER XVI. 

Periurethral Inflammations . .192 

Follicular and Periurethral Abscesses 194 

Paraurethral Ducts 194 

Treatment 195 

CHAPTER XVII. 
Hemorrhage 196 

CHAPTER XVIII. 

The Vaccination Therapy of Gonorrhea . . . .199 



LIST OF ILLUSTRATIONS 



Fig. 










Page 


i. — Gonorrheal pus . . . . . • . .n 


2. — Bougie a boule . 












24 


3. — Urethroscopic tube 












28 


4. — Light-carrier 












28 


5. — Cocaine syringe 












30 


6. — Meatotome . 












3 1 


7. — Spatulum and curette 












34 


8. — Urethroscopic pipette . 












35 


9. — Urethroscopic sound . 












35 


10. — Capillary catheter 












36 


n. — Drop syringe, . . . 












36 


12. — Intraurethral knife 












36 


13. — Small curve of Dittel . 












7i 


14. — Middle curve of Dittel 












7i 


15.— Large curve of Dittel 












7i 


16.— Stone-searcher . . . 












72 


17. — Irrigating catheter 












73 


18. — Irrigating catheter 












• 73 


19. — Injector . 












73 


20.— Instillator . . 












74 


21.— Perforated explorator . 












74 


22. — Sound for anterior urethra 












• 75 


23. — Sound with Dittel's short curve 










75 


24. — Sound with Dittel's large curve 










: 75 


25. — Sound with Guyon's curve . 










• 75 


26. — Urethrotome 






. 


• 77 


27. — Dilator for anterior urethra 








. 




■ 78 



XI 



Xll 



LIST OF ILLUSTRATIONS. 



Fig. 

28. — Dilator for posterior urethra (Dittel curve) 

29. — Dilator for posterior urethra (Guyon curve) 

30. — Dilator for anterior and posterior urethra (Dittel 

curve) ..... 
31. — Dilator for anterior and posterior urethra (Guyon 

curve) ..... 
32. — Transverse cut of dilators 
^^. — Dilating irrigators 
34. — Mercier catheter with single curve 
35. — Mercier catheter with double curve 
36. — Cylindrical bougie 
37. — Conical bougie with bulbous end 
38. — Conical bougie .... 
39. — Filiform bougie .... 
40. — Tour over the abdomen 
41. — Small syringe for the patient to use 
42. — Hand syringe .... 
43. — Method of irrigation .. 
44. — Irrigator ..... 
45. — Drawing for history record . 
46. — Instrument for intraurethral application 

current .... 
47. — Urethrotome (Kollmann) . 
48. — Semen mixed with prostate secrete 
49. — Cooling catheter 
50. — Massage instrument . 
51. — Psychrophore .... 
52. — Congestive hyperemia 



of galvanic 



Page 
78 
78 

80 

80 
81 
82 

83 
83 
84 
84 

84 

85 

89 
IOO 

IOI 

I08 

IO9 

125 

135 
I50 
l6o 
168 
171 
171 
190 



GONORRHEA 

ITS 

DIAGNOSIS AND TREATMENT. 



CHAPTER I. 
ANATOMY OF THE URETHRA. 

In the male, the edges of the ectodermal portion of 
the urogenital sinus unite to form a closed canal whose 
commencement is at the mouth of the ejaculatory duct, 
the ending being at the glans penis. In the female 
the edges of the urogenital sinus do not unite, but form 
the vestibulum vagince. The female urethra is formed 
by the endodermal portion of the urogenital sinus. 
It corresponds, embryologically, to the upper half of 
the pars prostatica, and, like the latter, serves exclu- 
sively as a urinary passage. That portion of the male 
urethra which is formed by the ectodermal urogenital 
sinus serves not only for urinary purposes but also is 
the means of exit of the spermatozoa. 

The length of the male urethra varies not only in 
different individuals, but also in the same individual, 
depending on the presence and the degree of hyperemia. 
In the adult male a long urethra is said to be one that 
measures about 10 inches in length; a short urethra 
measures about 6 inches. The average length of the 
adult male urethra is 8 inches. 



2 TREATMENT OF GONORRHEA. 

The average length of the pars fixa of the urethra in 
the adult male is 4 \ inches ; that of the pars pendulosa, 
3J inches. 

The urethra is divided into four portions: (1) 
Intravesicular portion* \ inch; (2) prostatic portion, 
1 inch; (3) membranous portion, \ inch, and (4) cavern- 
ous portion, 6 inches. 

THE INTRAVESICULAR PORTION. 

This portion of the urethra is ill-defined and in many 
animals may be absent. It is well-marked in the human 
male, owing to the moving upward of the ureteral open- 
ings. In the primitive state, the ejaculatory ducts and 
the ureteral openings lie close together, and the ureters 
open directly into the urethra. The urinary bladder 
must be looked on as a later development, one which 
serves merely as a reservoir. The original urinary 
passages consist of ureters and urethra and the trigonum, 
which corresponds, embryologically, to the intravesicu- 
lar portion of the urethra. 

The intravesicular urethra is triangular in shape, 
and is bounded at each posterior angle by the orifice 
of the ureters. The anterior inferior angle is occupied 
by the orifice of the prostatic urethra. Passing from 
one ureteral opening to the other, is a fold of mucous 
membrane forming a curve, which is caused by the 
projection of muscular fibers which join the two ureters. 
This fold is called the plica ureterica. 

The muscular fibers of the intravesicular portion of 
*Kalischer: Die Urogenitalmuskulatur des Dammes, Berlin, 1900. 



ANATOMY OF THE URETHRA. 3 

the urethra are continuous above with the muscular 
fibers of the ureters, and below with those of the ure- 
thra; but there is no connection whatever between 
the muscular fibers of the trigonum vesica and those of 
the bladder. The muscular fibers of the bladder are 
much coarser than those of the intravesicular urethra, 
and the muscular network of the bladder is much looser 
than that of the urethra. 

The mucous membrane of the trigonum vesica con- 
tains glands similar to those found in the other parts of 
the urethra. No glands are found in the mucous mem- 
brane of the bladder. The color of the mucous mem- 
brane of the intravesicular urethra of the living subject 
is darker than that of the bladder. The epithelial 
covering of this mucous membrane is of the stratified 
squamous variety. 

In persons having only one kidney the trigonum 
vesica is absent. 

THE PROSTATIC URETHRA. 

The prostatic urethra is that portion of the urethra 
which lies between the intravesicular and the membran- 
ous parts. Its length varies between f to 1 inch. Its 
mucous membrane is covered by epithelium, which in 
the upper portion resembles the epithelium found in the 
intravesicular portion of the urethra, and in the lower 
portion resembles the epithelium covering the mucous 
membrane of the membranous part of the urethra. 

At about the middle of the floor of this canal is a 
well-marked longitudinal ridge, the colliculus seminalis- 



4 TREATMENT OF GONORRHEA. 

which is formed by the elevation of the mucous mem- 
brane and the underlying tissues. The upper end of the 
colliculus is lost in the orifice of the bladder; the lower 
end terminates abruptly, but is continued as a smaller 
ridge, the crista urethralis. This small ridge terminates 
at about the middle of the membranous urethra in a 
bifurcation. 

On the slope of the lower part of the colliculus are 
the slit-like openings of the ejaculatory ducts. Between 
these is found a depression, the utriculus prostaticus, or, 
as it has been designated by Weber, who discovered it, 
the uterus masculinus. This structure is developed 
from the lower ends of the rudimentary Muellerian 
duct, and is therefore homologous with the uterus in 
the female. 

On either side of the colliculus seminalis may be 
seen a slightly depressed fossa, the prostatic sinus, whose 
floor is perforated by the orifices of the prostatic ducts. 

The anatomical relation of this portion of the urethra 
to the prostatic gland makes it necessary to review 
briefly, at this time, the anatomy of the prostate gland. 

According to Toureux,* the first vestiges of the pros- 
tate gland appear during the third month of intrauterine 
life in the form of a solid cord-like epithelial outgrowth 
from the urethral epithelium. In the fourth month 
this bud of epithelium becomes bifurcated, branching 
out to both sides, and in the fifth month the principal 
processes become hollowed out. 

* Toureux: Du tubercle chez le foetus humain. Jour, de l'anat., 
et de physio., 1889, T. 25. 



1 



ANATOMY OF THE URETHRA. 5 

The gland in the adult consists of from 30 to 50 
lobules. Its excretory ducts are quite long (J of an 
inch), and narrow (2-5-0- of one inch). 

The intracellular tissue of the gland consists of con- 
nective tissue and muscle fibers. 

Ruedinger* found that the intercellular tissue consti- 
tutes from one-half to two- thirds of the bulk of the gland 
in some cases, while in others the glandular tissue pre- 
dominated, even to the extent of constituting five-sixths 
of the bulk of the gland. 

The prostate gland of the adult resembles a chestnut 
in size and shape. Its base is directed upward and 
backward, and rests against the bladder. It is perfor- 
ated for the passage of the uterus masculinus, and the 
ejaculatory ducts. This canal divides the base into 
a ventral and a dorsal plate. The dorsal plate is the 
thinner of the two, and is called the isthmus or commis- 
sura prostatica. The ventral plate corresponds to the 
middle lobe of the prostate gland. 

The apex of the gland is directed forward and down- 
ward, and touches the deep layer of the deep perineal 
fascia. The two side lobes are connected with each 
other by the isthmus. 

The posterior surface of the gland, which rests on 
the rectum, is smooth and flat, and is marked by a slight 
longitudinal furrow, the incisura prostatica. The 
anterior surface is convex. It is placed about j of an 
inch behind the lower part of the symphysis pubis. 



*Ruedinger: Zur Anatomie d. Prostate, Munchen, 1883. 
2 



6 TREATMENT OF GONORRHEA. 

THE MEMBRANOUS URETHRA. 

The membranous urethra extends from the apex of 
the prostate gland to the bulb of the penile urethra. 
It measures about \ inch in length. The longitudinal 
folds of mucous membrane are very well-marked in this 
portion of the urethra. All of these folds, except the 
crista urethralis, disappear when the urethra is distended. 

The epithelium covering this portion of the mucous 
membrane is of the non-ciliated simple columnar type. 
The mucous membrane of the posterior urethra is 
surrounded by two layers of non-striated muscle fibers. 
The fibers of the inner layer run in a longitudinal direc- 
tion, and the fibers of the outer layer in a circular direc- 
tion. The longitudinal fibers are continuous with those 
of the intravesicular portion of the urethra. 

The circular muscle of the male urethra is interrupted 
in its continuity and arrangement by the prostate gland, 
which forces its lobes between the fibers of the muscle 
coat, causing either a displacement or an absorption 
by pressure atrophy. In the female, this muscle forms 
a continuous circular coat, which gradually increases 
in thickness as it approaches the posterior end of the 
urethra, where it constitutes, in the female as well as in 
the male, the sphincter vesicce triagonalis (Kalischer), 
which is identical with what is ordinarily termed the 
sphincter vesicce. 

The investigations of Reliquet, Frank, Langley, 
Sherington, Zuckerkandl and Zeissl have shown that 
this muscle is in a state of involuntary tonic contraction 
{sphincter tonus), and when in a state of rest it keeps 



ANATOMY OF THE URETHRA. 7 

the urethra closed, preventing the accumulating urine 
from leaving the bladder, except when its nerves are 
stimulated during the act of micturition, when the mus- 
cle relaxes. This muscle joins the transverse muscle 
fibers of the bladder, but it does not exchange fibers with 
the latter. 

Peripheral to the involuntary muscles the urethra is 
surrounded by a uniformly striated circular muscle, 
which Kalischer named the musculus sphincter uro- 
genitalis. In the adult its course and outline have been 
modified by changes taking place in the growing bony 
pelvis and the rapid growth of the prostate and of Cow- 
per's gland. The posterior part of this muscle is de- 
scribed by Henle, who made his investigations on the 
adult male, as the sphincter vesica externus. Its func- 
tion in the adult male has been changed from a com- 
pressor of the urethra to a compressor of the gland, 
and it is now a part of the sexual apparatus. 

The middle portion of the sphincter musculus uro- 
genitalis lies in the membranous portion of the urethra, 
and is known as the compressor urethra, accelerator 
urince, or sphincter urethra membranacea, but inasmuch 
as it is a voluntary muscle, it cannot perform true sphinc- 
teric duties. 

The non-striated muscle and the sphincter of the 
membranous urethra, which in this location is about 
four or five times as thick as the former, surround the 
urethra on the ventral and lateral surfaces. On the 
dorsum the fibers of both these muscles loose their cir- 
cular course, interlace freely with each other, thus 



8 TREATMENT OF GONORRHEA. 

surrounding the membranous urethra in the form of 
a loop. 

The sphincter of the membranous urethra and the 
deep transverse muscle of the perineum form a three- 
cornered muscle plate, which spreads out in the pubic 
arch. The membranous urethra penetrates this muscle 
plate at about its middle, where the plate is about as 
thick as the urethra is long. The muscle plate is covered 
on both sides by fascia. The fascia covering the under 
surface is sometimes called the ligamentum triangulare 
urethra. Cowper's glands are situated just behind 
this ligament on either side of the urethra. 

CAVERNOUS URETHRA. 

The cavernous urethra is the longest of the four 
divisions of the urethra. It corresponds to all of the 
anterior urethra. Its average length is about 6 inches. 
It extends from the termination of the pars membran- 
acea to the meatus urinarius. It presents two dilatations, 
one at the bulb and the other at the jossa navicularis. 
For descriptive purposes, it is sometimes divided into 
bulb and shaft. 

This is the only portion of the urethra which contains 
the crypts of Morgagni and the glands of Littre. One 
of the crypts of Morgagni, which is larger than any of 
the others, is situated in the jossa navicularis about 
i to i J inches from the external orifice. It is called 
the lacuna magna. The glands of Littre occasionally 
reach into the spongy and cavernous bodies, and may 
even form conglomerations there. Lichtenberg found 



ANATOMY OF THE URETHRA. 9 

3240 glands in one square centimeter of the urethral 
mucous membrane;* this would make about 20,000 to 
the square inch. The excretory ducts of these glands 
are long and often end in the crypts of Morgagni. 

In the posterior third of the pars cavernosa are the 
slit-like openings of the excretory ducts of Cowper's 
glands. Each duct is two to three millimeters long. 
The proximal end of the duct pierces the inferior layer 
of the deep perineal fascia, traverses the bulb, and then 
courses in the submucosa of the shaft until it opens on 
the surface of the mucous membrane. 

The walls of the urethra are collapsed, and the 
several parts of the canal can be distinguished with 
ease by the form that is assumed by the collapsed canal. 
If transverse sections were to be made, we would find 
a vertical slit in the glans penis, a horizontal slit in the 
pars cavernosa, a star-shaped slit in the pars membran- 
acea, and a slit like an inverted Y in the pars prostatica. 

* Lichtenberg, Zeitschr. f. Urologie, Bd. I, H. 12, Dec, 1907. 



CHAPTER II. 

PATHOLOGY OF GONORRHEA. 

THE GONOCOCCUS. 

In 1879 Neisser found an organism of characteristic 
shape and position in the discharges of a large number 
of cases of gonorrhea occurring in both men and women. 
Bumm was the first to cultivate the germ on artificial 
media, and he also succeeded in reproducing the dis- 
ease by inoculating the female urethra with a pure cul- 
ture of the organism in its twenty-second generation. 
The gonococcus has a biscuit-shape, or as Bumm calls 
it, a coffee bean shape; that is, the oblong body shows 
in the middle line a light streak. 

The average length of the gonococcus is 1.25 microns 
and the average transverse diameter is from 0.6 to 0.8 
microns. The size varies considerably, especially in 
cultures. In the urethral discharges the organism is 
found usually occupying the cells and in irregular 
heaps in the protoplasm of the polynuclear leucocytes, 
but never in nucleus of the cell. 

The gonococcus is stained easily with all the anilin 
dyes. It is negative to the Gram stain, that is, it is 
decolorized. This is an important point in diagnosis. 
The best stain and the one used most widely for stain- 
ing the gonorrheal discharges is Loefiier's alkaline 
methylene blue. 

10 



PATHOLOGY OF GONORRHEA. n 

Methylene blue, gentian violet and Bismarck brown 
are anilin dyes. The first-named is used in Loeffler's 
alkaline methylene blue stain, and the two last-named 
are used in the Gram stain. These anilin dyes are on 
the market in the form of dry crystalline powder. When 
ordering, it is best to specify Gruebler, since his products 




FlG. i. — Specimen of gonorrheal pus. Leitz: Oil immersion 
T J 3 ocular No. i. The middle of the microscopical field shows a 
polynuclear leucocyte whose cellbody contains a number of 
gonococci. 

are the most reliable. The so-called stock solutions 
of these stains should always be at hand; from these 
small quantities of stain are prepared for immediate use, 
as they deteriorate if kept for some time. They are 
put in small bottles with stoppers and pipettes. 

The stock solutions are made by adding one part of 
the powered dye to four parts of absolute alcohol. A 



12 TREATMENT OF GONORRHEA. 

glass stoppered bottle is filled to one-quarter of its cap- 
acity with the dye and sufficient absolute alcohol is 
added to fill the bottle. An excess of dye may be used 
to ensure saturation. The excess remains undissolved 
in the bottom of the bottle. 

In Gram's method of staining anilin water gentian 
violet is used; it is prepared as follows: A teaspoonful 
(4 grams) of anilin oil is shaken thoroughly with 2% 
ounces (72 grams) of water. The mixture is filtered 
through filter paper until it is perfectly clear. To 10 
teaspoonsful of the filtrate one teaspoonful of concen- 
trated alcoholic solution of gentian violet is added. 
This stain decomposes easily, however, and should be 
prepared in small quantities only. 

The Gram staining is performed in the following 
way: A thin film of the material to be examined is 
prepared on a slide, dried in the air and fixed in the 
flame. It is stained for three to five minutes with the 
anilin water gentian violet. Pour off the stain, wash 
with water and immerse the specimen in Gram solution. 

Gram solution has the following formula: 

Iodine, 15 grains. 

Potassium iodide, 3i 

Distilled water Oj. 

Stain until the specimen turns a dark brown color. 
Wash with 95 per cent, alcohol until the color ceases to 
be given off, and the preparation is of grayish color. 
Bismarck brown may be used as a counterstain. Wash 
the specimen in water and mount in Canada balsam. 

Bismarck brown stain is prepared from the stock 



PATHOLOGY OF GONORRHEA. 13 

solution by adding 25 drops of the solution to one ounce 
of distilled water. 

Loeffler's alkaline methylene blue is made as follows : 

Sat. alcohol sol. of methylene blue, 30 

Sol. potass, hydra. (1 : 10,000), 100. 

The gonococcus does not grow on the culture media 
used ordinarily. It can be cultivated on human blood 
serum and particularly on human blood serum agar, as 
was shown by Wertheim. It can also be grown or 
cultivated on the blood serum of the hog, but not so 
successfully. It grows equally well on an alkaline, acid 
or neutral medium, nor is it necessary to add salt. 
A pure culture of the gonococcus can be kept alive for 
weeks, provided the medium contains sufficient mois- 
ture. The organism is not very resistant to high tem- 
peratures. Its temperature optimum is 36 Celsius; 
the mean and extreme temperature is 26 and 39 Cel- 
sius. The gonococcus succumbs in six hours to a tem- 
perature of 40 Celsius. 

The bacillus pyocyaneus, bacillus typhosus, staphylo- 
coccus, and cholera bacillus have an injurious influence 
on the growth of the gonococcus, either because of 
toxins elaborated by these germs or because of their 
decomposition products. It is impossible to produce 
an experimental gonorrhea in animals, although the 
animal can be killed with the gonococcus poison when 
this is produced elsewhere. The gonococcus is toxic 
for animals, but not infectious. 

In men its pathogenic properties are equal to those 



i 4 TREATMENT OF GONORRHEA. 

of the other pus-producing microorganisms. At the 
point of entrance of the gonococcus a localized inflam- 
matory process is set up, and from here metastasis to 
the various viscera take place. The gonococcus has 
been found circulating in the blood, and it is known 
to produce both septicemia and pyemia. 

Filtrates of cultures of the gonococcus are devoid of 
any poisonous qualities, and are not toxic either for 
man or for animals, unless some of the cocci have broken 
down, as sometimes happens in the case of old cultures. 
The subcutaneous injection of dead cocci is followed 
by a decided reaction which is manifested locally by 
an inflammation and systemically by fever. It is evi- 
dent, therefore, that the gonococcus produces an endog- 
enous toxic substance which is free in the animal and 
causes intoxication, but the germ does not produce any 
free toxin. 

The gonococcus does not convey any immunity 
against subsequent infections, although, after a time, 
it loses its virulence for the urethral mucous membrane 
on which it has had its habitat. When this germ is 
transplanted to another urethra, it produces an attack 
of gonorrhea, usually acute, although occasionally the 
disease takes a chronic course from its inception. 

ACUTE GONORRHEA. 

The gonococcus which is thus transplanted propa- 
gates itself on and in the urethral mucous membrane, 
doing harm to the structures with which it or its meta- 
bolic products come in contact. 



PATHOLOGY OF GONORRHEA. 15 

The human body responds to the injurious invasion 
by a localized inflammatory hyperemia, accompanied 
by suppuration and edema of the part affected. The 
hyperemia is nature's most potent means of arresting 
and eliminating the infection. 

However, the infection is not always limited to the 
mucous membrane. It may invade the spongeous and 
even the cavernous bodies. The meshes of the erectile 
tissue are infiltrated. There is present endarteritis 
as well as periarteritis, and the veins are in a state of 
phlebitis. Fibrous coagula may form in the vessels 
of the parts most involved in the inflammatory process. 
The state of the lymph vessels is the same as that of 
the blood vessels. The lymph glands are swollen and 
tender to touch. Under certain conditions they may 
suppurate. All of the glandular structures of the mu- 
cous membrane are involved in the inflammatory proc- 
ess, a fact which is of special importance because of 
the prominent part played by glandular infection in 
chronic gonorrhea. 

In the excretory duct there is a marked epithelial 
proliferation, while the wall of the duct is thickened 
considerably by the infiltration of embryonal cells 
and leucocytes. The infiltration of the erectile tissue 
is limited mostly to the tissues surrounding the glands. 

According to observations made, these inflammatory 
processes start from the fossa navicularis, where the 
infection first establishes itself, and then spread over a 
more or less limited area. 

As a rule, the inflammation spreads upward along the 



16 TREATMENT OF GONORRHEA. 

course of the entire urethra, but its severity generally 
decreases with the distance from the primary focus of 
infection. It follows, therefore, that gonorrhea may 
be limited to the anterior urethra, although it may spread 
to the posterior urethra. 

Mention must be made at this point of the action of 
the sphincter of the membranous urethra and its sup- 
posed power of limiting gonorrhea to the anterior urethra. 
This muscle is believed to keep the urethra closed or 
collapsed by a firm tonic contraction, thus preventing 
the spread of the gonorrheal infection from the anterior 
to the posterior urethra. But this muscular plate, 
which surrounds the membranous urethra and is 
enclosed by the two layers of the triangular ligament, 
is made up of striated voluntary muscle fibers, which, 
according to physiologic laws, are relaxed when in a state 
of rest and generally do not have a sphincteric action. 
Suppose, for a moment, that this muscle were a true 
sphincter, and that it did keep the urethra tightly closed ; 
then the question would arise, whether a sphincter mus- 
cle has the power of arresting an infection as virulent 
as that of the gonococcus ? This can unhesitatingly be 
answered in the negative. 

Finger stated that posterior infection occurs in from 
60 to 80 per cent, of all cases of gonorrhea. Jadassohn 
gives the percentage as being from 60 to 70. Therefore, 
we consider the affection of the posterior urethra as 
being a part of and not a complication of the gonorrhea. 

After some weeks, especially under rational treat- 
ment, the acute inflammation subsides. The gonococci 



PATHOLOGY OF GONORRHEA. 17 

diminish in number, the pus gradually disappears, 
and the infiltration is absorbed, at least in part. 
The congestion of the blood vessels lessens and the 
epithelium attempts to regenerate itself, although in 
doing so it does not resume its original columnar 
form. 

In the meantime, all the objective manifestations of 
the disease may have disappeared; there is no more 
discharge of pus from the meatus, and a microscopic 
examination of a smear preparation of the discharge may 
fail to reveal any gonococci. Nevertheless, the gono- 
cocci have not disappeared entirely. They are hidden in 
the depths of the tissues, lying in the smaller or larger 
masses of infiltrates that have remained unabsorbed, 
and in the lumina of the infected glands. The urethro- 
scope usually reveals these lesions in the mucous mem- 
branes. They mark the onset of a chronic gonorrhea. 
It is, therefore, of importance to be mindful of the fact 
that the apparent absence of gonococci does not just- 
ify discharging the patient as cured. 

CHRONIC GONORRHEA. 

Chronic gonorrhea is the result of the progressive 
changes which take place in the inflammatory foci which 
remain after the acute stage of the disease has passed. 
Speaking pathologically, a chronic gonorrhea is said to 
begin with the first deposit of connective tissue fibers 
in the patchy cellular infiltrations of acute gonorrhea. 
The time of its appearance varies, but it usually takes 
place at about the end of the second month of the acute 



18 TREATMENT OF GONORRHEA. 

infection. Its onset is marked usually, although not 
necessarily, by a decrease in or an amelioration of acute 
symptoms. 

The most important lesions of a chronic gonorrhea 
take place in the mucosa proper. Their commence- 
ment is marked by the appearance of an inflammatory 
infiltrate, more or less rich in embryonal cells, pus cor- 
puscles, and epithelioid cells. This infiltration may 
be so intense as to cause the outlines of a corium to 
vanish entirely. The infiltrate invades the glands 
and crypts and their surrounding tissues, which also 
become well vascularized by the formation of new 
blood vessels. In this way it happens that the surface 
assumes a granulating appearance, which in extreme 
cases results in the production of papillomata. 

The crypts of Morgagni are invaginations of the 
mucous membrane. Their structure is identical with 
that of the mucous membrane. The infiltration of the 
pericryptic tissue with embryonal cells and leucocytes, 
and the vascular dilatation which accompanies this in- 
filtration cause a swelling of the crypts and a crater- 
like gaping of their mouths. The subsequent fi- 
brous change shows itself in one of two ways. These 
crypts either retreat, atrophy and disappear, or their 
excretory ducts are stopped up. The crypts them- 
selves are filled with cellular debris and are thus trans- 
formed into cysts, which appear on the surface of the 
mucous membrane as whitish nodules. In rare in- 
stances these cysts suppurate, producing periurethral 
abscesses and fistulae. 



CHAPTER III. 

DIAGNOSIS OF GONORRHEA. 

INSPECTION AND PALPATION. 

While the patient undresses, carefully inspect his 
clothing. The discharges of an acute gonorrhea usu- 
ally produce spots on the clothing that have well-de- 
fined borders and that are greenish-yellow in color. 
When the urethritis is subacute or chronic in character, 
the discharge produces large, ill-defined and only slightly 
pigmented spots. Next, note whether any inflam- 
matory changes are present, such as redness and swell- 
ing of the lips of the meatus. Observe carefully the 
nature of the discharge from the urethra; whether it is 
rich, creamy or milky, or only mucoid in character. If 
the flow is scanty, the urethra will be found glued to- 
gether, and on forcing it open a small quantity of pus 
escapes. It is always well to know how long it is since 
the patient urinated, and when the secretion is very 
scant, it is advisable to see the patient early in the morn- 
ing, before he has emptied his bladder. 

If no pus appears spontaneously, rub the lower sur- 
face of the urethra lightly from the bulb forward, and 
if this also fails to force out any discharge, then the urine 
should be examined in divided portions for inflamma- 
tory products. For this purpose one of the " glass 

3 21 



22 TREATMENT OF GONORRHEA. 

tests" should be used. This will also furnish some in- 
formation as to the location of the affection. 

The simplest of these tests is Thompson's two-glass 
test. The patient is asked to urinate into two glasses, 
approximately one-half of the flow being emptied into 
each glass. The first glass contains the pathologic 
products of the urethra, while the second glass con- 
tains the urine as it comes from the bladder. Cloudi- 
ness of the first portion and clearness of the second por- 
tion of urine point toward disease of the urethra. When 
pathologic products are found in both portions of urine, 
there is present an affection of both the urethra and 
the bladder. The latter statement is true only when 
the inflammatory process is not an acute one. 

In an acute gonorrhea the production of pus usually 
is so profuse that both portions of urine are turbid, 
even in those cases where the disease is confined to the 
anterior urethra. In the case of a posterior urethritis, 
some of the secretion may flow back into the bladder, 
when it becomes mixed with the urine contained in the 
bladder, thus clouding the second portion of urine 
voided. 

The pathologic products contained in the last por- 
tion of urine voided deserve special study because con- 
traction of the muscles may press out some of the secre- 
tion of the prostate gland and the seminal vesicles. 
For the porpose of studying this urine, Jadassohn in- 
stituted the three-glass test. The same procedure is 
followed as in the Thompson test, except that just be- 
fore the bladder is emptied entirely, the patient urin- 



DIAGNOSIS OF GONORRHEA. 23 

ates into a third glass, which will contain what is called 
the prostatic urine. 

More accurate information as to the location of the 
pathologic changes in the urethra may be obtained by 
the use of a method first proposed by Goldberger, the 
so-called diagnostic irritation method, and elaborated 
by Kollmann, who called it the five-glass test. If 
possible, this test should be made in the morning. With 
the patient standing, a straight catheter is introduced 
into the urethra up to the bulb. Irrigation is made 
with a large hand syringe. Not much pressure should be 
exerted, and there should be enough space between the 
catheter and the wall of the urethra to permit of the return 
of the irrigating solution. A clear aseptic or slightly 
antiseptic solution is used. The irrigation is continued 
until the fluid returns clear. The patient is then asked 
to urinate into three glasses, as is done in Jadassohn's 
method. In the first glass are placed the first washings 
of the anterior urethra, and in the second glass the last. 
The third glass contains the pathological products of 
the posterior urethra; the fourth glass those of the 
bladder, and the fifth glass those of the prostate gland. 

The test may be made more valuable by massaging 
the prostate before the last portion of urine is passed. 
Instead of the entire anterior urethra only sections of 
iKmay be washed out and the washings examined sepa- 
rately* Phimosis, balanitis, lymphangitic streaks, urin- 
ary nitrations, fistulas, varicocele, hydrocele, epididy- 
mitis, and orchitis should be looked for. The entire 

* Young: Johns Hopkins Hospital Report. Vol. 13, 1906. 



24 TREATMENT OF GONORRHEA. 

urethra is palpated. It rs either smooth throughout or 
rough and rigid in some parts. The normal 
urethra slides smoothly between the ends of 
^UII ^ e fi n & ers - It i s a ^ so advisable to palpate over 
the sound. The membranous and prostatic 
urethra are palpated best with the fingers in the 
rectum. The female urethra is palpated easily 
through the vagina. If no pus appears spon- 
taneously the urethra is emptied by massage. 
The finger after passing the pubic arch is well 
pressed upward in front of the pubic bone. 

INSTRUMENTAL EXAMINATION. 

In all acute inflammations of the urethra in- 
strumental examination is contraindicated. 
The most convenient instruments for endo- 
urethral examination is the elastic bulbous 
bougie, Guyon's explorateur a boule olivaire, or 
bougie a boule. (Fig. 2.) The bougie a boule 
carries on a slender shaft an olive-shaped head 
which is conical at its digital end and sharply 
cut off at its proximal end. The olive of the 
most frequently used bougies has a diameter of 
18 to 20, French scale. It is advisable to have 
the entire set of bougies, ranging in size from 
8 to 26. In the normal urethra the bougie 
passes through the anterior portion smoothly 
and without any resistance. At the isthmus a 
Fig. 2. slight obstruction is encountered. When this 

Bougie a . . . . . . ,. 

boule. obstruction is passed, the patient is conscious 01 



DIAGNOSIS OF GONORRHEA. 25 

the maneuver. In the whole length of the membranous 
urethra the bougie passes through less freely, while in 
the prostatic portion it moves easily until the internal 
orifice is reached, when a slight constriction is en- 
countered just before the bougie enters the bladder. 
In some instances the bougie may be caught in the 
prostatic sinus. (Dittel.) 

While passing through the prostatic urethra, the 
patient usually has a desire to urinate. The largest 
diameter of the head of the bougie being at its prox- 
imal end, the obstructions in the urethra are felt more 
plainly when the bougie is withdrawn than when it is 
introduced. In some cases the meatus is so small 
that it must be cut before an examination can be made. 
Occasionally in the young, and very often in the old, 
the bulbous urethra is very wide, so that the end of 
any inelastic instrument is caught in a sort of cul de sac. 
This obstruction may be overcome by lengthening the 
urethra by traction. Immediately behind the bulb is 
the isthmus, which usually can be passed readily, ex- 
cept in the case of very nervous individuals whose mem- 
branous urethra generally is hyperemia Then there 
is a reflex spasmodic contraction of the " membranous 
sphincter." A few drops of cocaine solution and a 
little patience on the part of the operator will over- 
come this obstruction. 

Any obstructions in the course of the urethra, except 
those mentioned above, are pathologic in nature. In 
the case of a stricture a sensation of unevenness is im- 
parted to the examining finger through the instrument. 



24 TREATMENT OF GONORRHEA. 

urethra is palpated. It rs either smooth throughout or 
rough and rigid in some parts. The normal 
urethra slides smoothly between the ends of 
the fingers. It is also advisable to palpate over 
the sound. The membranous and prostatic 
urethra are palpated best with the fingers in the 
rectum. The female urethra is palpated easily 
through the vagina. If no pus appears spon- 
taneously the urethra is emptied by massage. 
The finger after passing the pubic arch is well 
pressed upward in front of the pubic bone. 

INSTRUMENTAL EXAMINATION. 

In all acute inflammations of the urethra in- 
strumental examination is contraindicated. 
The most convenient instruments for endo- 
urethral examination is the elastic bulbous 
bougie, Guyon's explorateur a boule olivaire, or 
bougie a boule. (Fig. 2.) The bougie a boule 
carries on a slender shaft an olive-shaped head 
which is conical at its digital end and sharply 
cut off at its proximal end. The olive of the 
most frequently used bougies has a diameter of 
18 to 20, French scale. It is advisable to have 
the entire set of bougies, ranging in size from 
8 to 26. In the normal urethra the bougie 
passes through the anterior portion smoothly 
and without any resistance. At the isthmus a 
fig. 2. slight obstruction is encountered. When this 

Bougie a . . . . . - 

boule. obstruction is passed, the patient is conscious 01 



DIAGNOSIS OF GONORRHEA. 25 

the maneuver. In the whole length of the membranous 
urethra the bougie passes through less freely, while in 
the prostatic portion it moves easily until the internal 
orifice is reached, when a slight constriction is en- 
countered just before the bougie enters the bladder. 
In some instances the bougie may be caught in the 
prostatic sinus. (Dittel.) 

While passing through the prostatic urethra, the 
patient usually has a desire to urinate. The largest 
diameter of the head of the bougie being at its prox- 
imal end, the obstructions in the urethra are felt more 
plainly when the bougie is withdrawn than when it is 
introduced. In some cases the meatus is so small 
that it must be cut before an examination can be made. 
Occasionally in the young, and very often in the old, 
the bulbous urethra is very wide, so that the end of 
any inelastic instrument is caught in a sort of cul de sac. 
This obstruction may be overcome by lengthening the 
urethra by traction. Immediately behind the bulb is 
the isthmus, which usually can be passed readily, ex- 
cept in the case of very nervous individuals whose mem- 
branous urethra generally is hyperemia Then there 
is a reflex spasmodic contraction of the " membranous 
sphincter." A few drops of cocaine solution and a 
little patience on the part of the operator will over- 
come this obstruction. 

Any obstructions in the course of the urethra, except 
those mentioned above, are pathologic in nature. In 
the case of a stricture a sensation of unevenness is im- 
parted to the examining finger through the instrument. 



26 TREATMENT OF GONORRHEA. 

The sensation is that of the bougie jumping over a 
hard string. If the stricture is so tight that it cannot 
be passed by the bougie, the filiform bougie must be 
used, commencing with the smallest number and in- 
creasing the size gradually until the diameter of the 
stricture is ascertained. Many strictures are hard and 
ridge-like and stand out prominently from the surround- 
ing mucous membrane. It is possible for the filiform 
bougie to be caught in a pocket of the mucous mem- 
brane, or it may enter the narrow passage of the stric- 
ture somewhere at its middle. It is, therefore, a good 
plan not to try to pass the stricture with the first bougie, 
if it is caught in a pocket. A second bougie is intro- 
duced, and so on until either all the blind pockets have 
filled out with bougies, or until one bougie passes through 
the stricture. 

We may use conical or cylindric metal sounds in 
place of the bougies, but the information they impart 
cannot be compared with that given by the bougies. 
The infiltrations met with in chronic gonorrhea may be 
detected by passing a sound into the urethra and pal- 
pating with the hand on the surface. The membranous 
and prostatic urethra are palpated through the rectum. 

The introduction of a bougie into the urethra en- 
ables us not only to ascertain the degree of sensi- 
tiveness and character as to smoothness of the ure- 
thral mucous membrane, but it also is an easy means to 
determine the length of the urethral canal. The in- 
struments most suited for this work are Kutner's grad- 
uated bougie. 



DIAGNOSIS OF GONORRHEA. 27 

URETHROSCOPY. 

In a large percentage of cases of chronic gonorrhea, 
the pathologic changes consist in widespread infiltra- 
tions of a slight degree, but may cause serious disturb- 
ances. In other cases these changes are confined to 
small aggregations of inflamed and suppurating glands 
or crypts which, in spite of their small size, perpetuate 
the virulent infection and cause a constant discharge 
of pus. On the other hand, it is by no means certain 
that the existence of this condition is made manifest 
by symptoms. There may be no secretion what- 
ever, and the urine may not contain filaments for weeks 
or months, or even for years. Suddenly the patient is 
attacked by an acute gonorrhea, without having ex- 
posed himself to the infection. Such cases are by no 
means rare. The endo-urethral examination with the 
bulbous bougie, the sound and the urethrometer, while 
ordinarily of great service, in making a diagnosis, gives 
little information in these cases. They remain, there- 
fore, a mystery to the insufficiently equipped physician, 
and it is because of this that chronic gonorrhea is said to 
be incurable. 

In order to treat a disease successfully, a correct 
diagnosis must first be made. The most important in- 
strument with which to make a thorough examination is 
the urethroscope. The technic of urethroscopy is 
easy, but in order to draw correct conclusions from 
the results obtained with the urethroscope much ex- 
perience is needed as well as a thorough knowledge 
of the pathology of gonorrhea. The lack of these qual- 



28 



TREATMENT OF GONORRHEA. 



ifications on the part of the clinician probably explains 
why some textbooks on surgery speak lightly of this 
method of examination. 

Nitze, Oberlaender, Kollmann and Valentine have 
given us a urethroscope to be described below. It 




Fig. 3. — Urethroscopic tube with obturator. 

consists of a tube and obturator (Fig. 3), and a light- 
carrier with an incandescent lamp (Fig. 4). The 
urethroscopic tube carries at the visual end the disc, 
which holds a spur for the attachment of the light- 
carrier. The digital portion of the urethroscope is 




Fig. 4. — Light-carrier with incandescent lamp. 

cut off obliquely from the upper to the lower wall. 
Each tube is provided with an obturator which has 
stamped on its handle a number corresponding with 
that of the tube to which it belongs, and indicating 
the diameter expressed in Charriere scale. No. 30 is 



DIAGNOSIS OF GONORRHEA. 29 

equal to 10 millimeters, or one centimeter (J- inch). 
The distal end of the obturator is conical in shape, it 
closes the tube, and permits of easy introduction of the 
instrument into the urethra. It has a slit which 
facilitates its removal and prevents any suction action on 
the mucous membrane, with a consequent laceration. 

Kollmann uses a set of urethral tubes ranging in size 
from 21 to 31 Charriere. Valentine, of New York, uses 
a set ranging in size from 22 to 32 Charriere. 

The light-carrier constructed by C. G. Heynemann, 
of Leipzig, consists of a delicate metal tube open at 
both ends. At the distal end it supports a cup, which 
receives the incandescent lamp. To the proximal end 
is fastened at right angles a handle provided with a 
switch. Attached to one pole of the lamp is a long 
insulated wire which, when introduced into the tube of 
the light-carrier, is caught at the proximal end by a 
screw, which penetrates the insulation when tightened 
and completes the circuit. 

The other pole is provided with a short, not insulated, 
wire, which remains in contact with the wall of the 
tube of the light-carrier. Before beginning the urethro- 
scope examination, the apparatus should be tested. 
The incandescent lamp should throw a clear white 
light. The electricity is best furnished by a storage 
or a dry battery, because the transformers, especially 
the portable varieties, are still very unreliable. 

The operator and his assistant wash their hands 
with the same care and thoroughness as is done for a 
surgical operation. The urethroscopic tubes and ob- 



So TREATMENT OF GONORRHEA. 

turators are boiled both before and after the examin- 
ation. In special cases it is necessary to boil the light- 
carrier. The screw which fastens the lamp to the light- 
carrier is loosened, and the lamp is taken out. The 
lamp can be disinfected in a germicidal solution, or 
it can be thrown away. The latter is the more advis- 
able, if the apparatus has been used in a tuberculous 
case. 

In some cases it is advisable to anesthetize the ure- 
thra with a three per cent, solution of cocaine. Koll- 
mann constructed a syringe (Fig. 5) of two cubic centi- 
meters volume, which is provided with exchangeable 




Fig. 5. — Kollmann's cocaine syringe. 

tips. These tips are boiled after each examination and 
are kept in a solution of bichloride of mercury ready 
for further use. The cocaine solution is kept in con- 
tact with the urethral mucous membrane for about 
five minutes. The absorption of the fluid can be aided 
by slight massage of the parts to which the solution 
has been applied. 

The cocaine slightly changes the appearance of the 
mucous membrane; therefore, the first examination 
should be made previous to the application of the co- 
caine. If a dilatation follows the urethroscopic ex- 
amination, it is best to postpone the cocainization until 
after the examination. 



DIAGNOSIS OF GONORRHEA. 31 

If the meatus is found to be too narrow to admit of 
the passage of the smallest-sized urethroscopic tube, 
we should try to stretch it as much as is necessary. 
If a sufficient dilatation has not been attained after 
three or four attempts, meatotomy is indicated. It is 
best performed by means of Oberlaender's meatotome 
(Fig. 6). Before the urethroscopic tube is introduced, 
it should be lubricated with sterile glycerine, or, if the 
meatus is tight, sterile vaseline or oil may be used in- 
stead of the glycerine. As a rule, however, oily sub- 



Fig. 6. — Oberlaender's meatotome. 

stances should not be used if their use can be avoided, 
because they are not soluble in water, and they can be 
removed only with difficulty. 

The operator takes his position to the left of the 
patient. He holds the urethroscope in his right hand, 
while with the fingers of the left hand he opens the 
meatus. Having passed the fossa navicularis, it is 
not difficult to push the tube to the end of the bulb. 
Force should not be used in any of these procedures, 
because in certain pathologic conditions the mucous 
membrane bleeds easily, and this bleeding would inter- 
fere with the making of an accurate examination. 

When the instrument reaches the bulb, the obtruator 
is withdrawn and the funnel formed by the mucous 
membrane closing in over the end of the tube is dried 
and cleaned with a pledget of cotton wound round the 



32 TREATMENT OF GONORRHEA. 

end of an uncut match. The cotton must be aseptic. 

The light-carrier is then introduced and fastened to 
the disc. The examination is done by gradually re- 
tracting the tube while keeping the funnel clean. Ob- 
serve any change that takes place in the shape of the 
funnel and note the appearance of colored fluid. The 
latter denotes a secretion from the diseased mucous 
membrane. Throughout the examination the urethro- 
scope should be kept in the long axis of the urethra, so 
that the walls of the latter can be examined simultane- 
ously. If it is desired to examine a certain area more 
particularly, the instrument is turned to that side. 

The introduction of the straight tube into the posterior 
urethra is disagreeable to the patient, and the affections 
of the sexual glands, like those of the prostate, do not 
show distinctly on the surface of the urethral mucous 
membrane. For these reasons urethroscopy of the 
posterior urethra is done less often than of the anterior 
urethra. Goldschmidt* constructed a urethroscope with 
an optical arrangement similar to that of a cystoscope. 
The urethra is examined while distended with water. 

In order to examine the posterior urethra, the patient 
is made to assume the lithotomy position, being placed 
well to the edge of the table, in order to get a good view 
of the perineum. The legs are flexed at the knees, the 
feet being kept a little higher than the body. On enter- 
ing the posterior urethra with a straight instrument it is 
necessary to push slowly and carefully, depressing 
it well while passing the colliculus seminalis below the 

* Goldschmidt (Berlin), Munch, med. Wochenschr., Nov. 14, 1907. 



DIAGNOSIS OF GONORRHEA. 33 

horizontal plane. The direction of the force in this 
region should be from below upward. After passing 
the colliculus the obturator is withdrawn and the tube, 
if it is found to have entered the bladder, is retracted to 
the internal urethral orifice. 

The mucosa is cleaned with a pledget of cotton be- 
fore the light-carrier is introduced. The examination 
may be interfered with by the escape of urine from the 
bladder. To overcome this, Kollmann introduces the 
urethroscopic tube only as far as the anterior border of 
the colliculus. Encountering a slight obstruction and 
a certain sensation felt by the patient announce that the 
end of the tube is in the proper position. In this method 
it is advisable to depress the point of the tube to- 
ward the lower wall of the urethra. Kollmann starts 
at the colliculus seminalis and examines the urethra 
first from before backward to the internal orifice, and 
then from behind forward through the entire length of 
the posterior urethra. Not much can be seen in this 
part of the urethra when the smallest tube, No. 00= 
21 Charriere, is used, but No. 0=23 Charriere per- 
mits of a most satisfactory examination. Tube No. 1 
= 25 Charriere sometimes passes the colliculus with ex- 
treme difficulty, occasioning the patient more or less 
pain. A urethroscopic tube must be held firmly and 
well in the middle line when these tissues are examined, 
because the pressure of the muscles and the curve of 
the urethra easily change its direction and force it out. 

The mucous membrane of this portion of the urethra 
is very delicate. It bleeds very easily, thus preventing 



34 TREATMENT OF GONORRHEA. 

a thorough urethroscopic examination. A second at- 
tempt must be made, and this usually is successful. 

When examining the anterior urethra, it is best to 
make it a general rule to use the largest tube that will 
pass through the meatus. The larger the tube, the 
better, because a large tube unfolds the mucous mem- 
brane and admits a good light for examination. The 
open excretory ducts of glands are in full view and secre- 
tion is pressed out of the infected glands. In view 
of recent cases it is advisable to begin the examination 
by using the smallest tube, because the larger tube 
may disturb the tissues and interfere with the mak- 
ing of a correct diagnosis; or bleeding may take place, 
and make an examination impossible. 

Oberlaender uses a knee-joint obtruator in order to 




Fig. 7. — a, Spatulum. b, Curette. 

enter the posterior urethra. This instrument has not 
met with much favor, because the examination can be 
made without its use. When the meatus is small, 
Oberlaender sometimes makes use of a dilating tube, 
constructed like a vaginal speculum. Kollmann and 



DIAGNOSIS OF GONORRHEA. 35 

Oberlaender have devised small spatulas, curettes, pi- 
pettes, knives, capillary catheters, electrolytic sounds, 
straight and bayonet-shaped, with pointed, blunt and 
bulbous ends, and electric needles with single and 
double poles. The spatulas (Fig. 7), curettes and 




Fig. 8. — Urethroscopic pipette. 

pipettes (Fig. 8) are used to secure some of the secre- 
tion for microscopic examination from the funnel pro- 
duced by the mucous membrane or from the crypts of 
Morgagni. 
The small sounds (Fig. 9) are useful to press away 




Fig. 9. — Urethroscopic sound. 

folds of mucous membrane, to facilitate the inspection 
of diseased areas, and to find the point of attachment 
of papillomata, as well as to probe the open excretory 
ducts of diseased glands. The capillary catheter 
(Fig. 10) enables us to treat the diseased portion of 
mucous membrane with strong antiseptics, and it can 



36 TREATMENT OF GONORRHEA. 

also be used to irrigate the crypts of Morgagni. For 
this latter purpose the catheter is combined with a 
Guyon drop syringe (Fig. n). 




Fig. io. — Capillary catheter. 

The intraurethral knives (Fig. 12) are used to make 
stabs or incisions into infiltrations and to divide stric- 
tures (intraurethrotomy). The bayonet-shaped sounds 
with blunt or pointed platinum ends are used to destroy 




Fig. 11. — Guyon drop syringe. 

diseased gland ducts by electrolysis, and also to treat 
hard infiltrations. 

The appearance of the normal mucous membrane 
of the urethra varies with the general structure of the 




Fig. 12. — Intraurethral knife. 



penis. A small penis has a fine delicate mucous mem- 
brane, even when the person is tall and strong. This 
is especially true in the case of individuals who have 



DIAGNOSIS OF GONORRHEA. 37 

a poorly-developed glans penis, and when there are 
congenital adhesions of the prepuce. 

The color of the mucous membrane is dependent on 
the blood supply. In anemia it is pale and in hyper- 
emia it is of a bright red color. The application of co- 
caine or pressure by the urethroscopic tube causes the 
tissue to become pale. Not only do different urethral 
show different degrees of red, but there is also a change 
of color within the same urethra. 

The surface of the urethra within the glans penis 
is devoid of papillae, and has a very poor blood supply. 
It is pale in color, and its surface is smooth. The 
color changes to a deeper red, as soon as the sulcus 
caronarius is reached, and here also the longitudinal 
folds are first seen. The arrangement of these folds is 
very similar to that seen in the esophagus, and in the 
intestinal tract. Their purpose during micturition 
and erection is apparent. The urethra also has trans- 
verse folds, which serve a similar purpose as do the 
longitudinal. 

If the urethroscopic tube is withdrawn during the 
examination, the transverse folds are obliterated, on 
account of the traction put on the penis. The operator 
sees the mucous membrane in the form of a funnel, 
which shows in its middle a more or less well-defined 
opening called the central field. This field changes its 
shape in different sections of the urethra. In the glans 
penis it is in the form of a vertical, slightly oval slit, 
immediately behind the glans it is rounded in form, 
and at the beginning of the cavernous portion of the 



38 TREATMENT OF GONORRHEA. 

urethra it changes gradually into a transverse slit. 
The farther the advance is made into the bulbous ure- 
thra, the more the inferior wall bulges into the field 
at the expense of the superior, distorting the central 
field. 

The number of longitudinal folds in the normal 
urethra varies in different individuals, being from four 
to twelve in number. They are arranged like the spokes 
of a wheel, and are most marked toward the center of 
the field. It is advisable to study these folds carefully 
in the healthy normal urethra, because pathologic con- 
ditions are manifested by changes in the shape, num- 
ber and color of these folds. The normal mucous 
membrane almost always shows striae of a beautiful red 
color, while the mucosa in the background is of a light 
yellowish-red tint. The striae are best developed in 
a well- vascularized surface. They are generally absent 
in the anemic mucous membrane of a narrow urethra, 
and here the longitudinal folds are poorly developed. 

The excretory ducts of the crypts of Morgagni appear 
as small, slightly-grooved hollows of the same color or 
a slightly deeper shade than the surrounding mucous 
membrane. At times they are large, and there may be 
seen distinct small cavities which resemble in appearance 
the prick of a needle. They are seen mostly in the 
upper wall, but only when a very careful examination 
is made. In the healthy urethra they are level with the 
membrane. 

The glands of Littre are found throughout the ure- 
thra, but are visible only when the mucous membrane 



DIAGNOSIS OF GONORRHEA. 39 

is diseased. They appear as red spots and remain 
visible a long time after the disappearance of the infec- 
tion. In many cases these glands are invisible because 
their outlet is covered over by epithelium and connec- 
tive tissue. 

The excretory ducts of Cowper's glands open into 
the lower wall of the urethra at the posterior portion 
of the shaft. In many cases the opening of these ducts 
is surrounded by a fold of mucous membrane and is 
then recognized easily in the endoscopic tube. This 
membranous fold has the shape of an inverted V, the 
closed end of the V pointing toward the isthmus, the 
open end toward the external orifice. When this fold 
of mucous membrane is very well developed, it is often 
combined with a congenital diverticulum (Kollmann). 

This is the appearance of the mucous membrane of 
the anterior urethra in strong and healthy subjects 
who have a well-developed penis. In the anemic 
patient and in those who are poorly developed, the 
mucous membrane is thick and colorless. It has neither 
longitudinal folds nor striae. The condition of this 
membrane may at first sight suggest a pathologic change 
but on closer examination the surface is seen to have 
a uniform appearance, which is never seen in disease. 

Another point of importance in- arriving at a diagnosis 
is the smoothness and brilliancy of the lining epithelium. 

The color of the normal and well-formed posterior 
urethra is usually much darker than that of the anterior. 
In the posterior portion of the prostatic urethra little 
of interest is found. The funnel is always short and 



40 TREATMENT OF GONORRHEA. 

closed. The mucous membrane is smooth, moist, and 
dark red in color. Folds are practically absent. While 
withdrawing the tube there gradually appears in the 
lower half of the field a projection, the colliculus sem- 
inalis. While it shows individual differences, it usually 
presents itself as a low oval- shaped body of the size of 
a split pea, but rather more elongated. Its size is 
generally dependent on the caliber of the urethra and 
the degree of development of the penis. Its surface is 
generally smooth, but when of large size it appears to 
be furrowed. This appearance is due to two or three 
small folds of mucous membrane. 

While passing this region the membranous funnel is 
obliterated almost completely by the projection of the 
body of the colliculus into the open end of the urethro- 
scope tube. The mouth of the uterus masculinus is 
seen in some cases. More seldom do we see the ejacu- 
latory ducts. The openings of the excretory ducts of 
the prostatic glands which are situated at either side of 
the colliculus are seen quite often. The appearance of 
the ejaculatory ducts is similar to that of the crypts 
of Morgagni. The mouth of the sinus pocularis is 
large and often is open. 

The smallest ducts are the ducti prostaticce, which 
resemble hypertrophic glands of Littre. Oberlaender 
found that in cases treated for some time with instilla- 
tions of a strong nitrate of silver solution, as is done 
in Guyon's deep injections, an argyrotic discoloration 
of the mouth of the excretory ducts takes place, making 
the ducts easily visible. In the adjoining membranous 



DIAGNOSIS OF GONORRHEA. 41 

urethra the continuation of the colliculus seminalis is 
recognized as a more or less prominently projecting 
ridge of mucous membrane. The ridge usually reaches 
to or passes the middle of the membranous section of 
the urethra, although in some instances it is missing. 
The membranous urethra has a short, closed funnel, 
and often a large number of longitudinal folds. At the 
borderline between the membranous and the anterior 
urethra is the isthmus bulbi of the membranous urethra. 

In the posterior urethra the tube is in nearly a hori- 
zontal position ; it rights itself as soon as its end reaches 
the anterior urethra, the deviation from the horizontal 
plane being from 45 to 90 . Further examination 
should be done between those angles. 

The bulb is recognized at once by the sac-like width 
of the lower half of the wall. The inspection of the 
intravesicular part of the urethra is done with the 
cystoscope. It reveals this part of the urethra as a 
triangular, smooth, glistening surface of a light yellow- 
ish-red color. The color is of a deeper red than the 
surrounding mucous membrane of the bladder, and is 
caused by a more abundant supply of blood-vessels 
and by the nearness of the prism of the cystoscope to 
the mucous membrane of the trigonum. The nearness 
also causes the blood-vessels to be magnified and 
brought out more, and the heat caused by the cysto- 
scopic lamp may produce more or less of a hyperemia, 
especially if the examination lasts for any considerable 
length of time. 



CHAPTER IV. 
VARIETIES OF GONORRHEA. 

The gross changes in the urethra occurring in the 
course of a chronic gonorrhea are the result of a pro- 
gressive pathologic process beginning with the first 
deposition of connective tissue fibers into the cellular 
infiltrations seen in the course of an acute gonorrhea 
and ending with the complete transformation of the 
cellular elements into scar tissue. 

Oberlaender divides the infiltrations of chronic gon- 
orrhea into two main groups, according to the stage to 
which the deposition of connective tissue has advanced. 
These two groups are the soft and the hard. The soft 
infiltrations are those which do not contain any appre- 
ciable amount of connective tissue. This stage of the 
inflammation increases the intensity of the normal red 
color of the mucous membrane. To the second 
group belong all those infiltrations in which the deposi- 
tion of connective tissue is marked. Here the intensify 
of the red color of the affected mucous membrane is 
diminished. 

Oberlaender subdivides the hard infiltrations into 
three groups, according to the extent to which the hyper- 
plasia of the connective tissue has encroached on the 
lumen of the urethra. To the first division belong the 
infiltrations that are of slight degree, or chronic gonor- 

42 



VARIETIES OF GONORRHEA. 43 

rhea of the first degree, where the lumen of the urethra 
has not suffered to a marked extent. To the second 
division belong all the hard infiltrations that are of 
medium degree, or chronic gonorrhea of the second 
degree, when the lumen of the urethra has been reduced 
in size so that a urethroscopic tube, No. 23, cannot be 
passed without lacerating the tissues. The infiltrations 
that cause a more pronounced narrowing of the urethra 
than this belong to the third division, or gonorrhea of 
the third degree. 

Chronic gonorrhea of the first degree and the lesser 
forms of the second degree correspond clinically to 
what are termed by Otis, of New York, strictures of a 
wide caliber. Chronic gonorrhea of the third degree 
corresponds clinically to what we generally call strictures. 
Pathologically, a stricture is a diminution in the elastic- 
ity of the urethra caused by the deposition of connective 
tissue in the walls of the urethra, so that every case of 
chronic gonorrhea is a case of stricture. 

On the basis of the pathologic changes that take 
place in the glands and crypts, Oberlaender further 
subdivides chronic gonorrhea into the moist or glandular 
and the dry or follicular varieties. In the glandular 
form the duct of the inflamed gland is swollen and 
injected, forming a little projection which at the height 
of the inflammation may be surmounted by a desquam- 
ating and injected mucosa. The discoloration varies 
from light to blood-red. The mouth of the duct may 
gape widely, showing the interior, or it may be stopped 
up with inspissated secretion. Within the area of the 



44 TREATMENT OF GONORRHEA. 

most marked infiltration of the mucosa are found the 
glands that are most affected; they therefore appear 
to be more numerous in the center of the patch than 
at the periphery. 

In the follicular or dry form the duct can be seen with 
a urethroscope only in exceptional cases. According 
to Neelson, the gland is converted into a subepithelial 
cyst which is filled with colloid material. 

The crypts being simple depressions in the mucous 
membrane are subject to the same diseases that affect 
the membrane, but in some instances they alone are in- 
fected, the neighboring structures not being involved in 
the inflammatory process. Under such circumstances 
the crypt appears as a red projection of about the size 
of a pinhead. On its side is seen the excretory duct as 
a small groove with shiny borders. The duct either 
discharges spontaneously or on pressure. The secre- 
tion is more or less purulent in character. If the in- 
flamed crypt is situated in the middle of a patch of infil- 
tration, it projects less above the surface. 

In the follicular or dry form, the excretory ducts of 
the crypts are closed and hidden from view, and the 
crypts themselves are filled with the inspissated products 
of inflammation and with cellular debris. They pro- 
ject above the mucous membrane and appear as whitish 
or yellowish translucent spots. These follicular patches 
are palpable as hard nodules of about the size of a pea, 
particularly though when the urethra is dilated by a 
hard instrument. 

The cases of both the moist and the dry varieties of 



VARIETIES OF GONORRHEA. 45 

infiltrations occur with equal frequency. If there 
is any difference in the frequency of their occurrence, 
it is in favor of the dry form. The latter is found disso- 
ciated from the moist form in cases that have not as 
yet been subjected to instrumental treatment, such as 
dilatations, which changes the urethroscopic picture. 
The glandular openings again make their appearance 
on the surface, and the follicular form of infiltration 
is converted into the glandular form as a part of the 
retrogressive development, which is taking place under 
the guidance of the graduated dilatation during the 
process of healing. 

The division of chronic gonorrhea into the varieties 
just described is more or less an arbritary one, and it is 
used here only for the sake of clearness of description. 
Of course, by reason of the great diversity of this affec- 
tion, transitional and mixed cases occur much more 
often than typical cases. 

SOFT INFILTRATIONS. 

The clinical features of this affection are embraced 
in the term subacute gonorrhea. Inasmuch as the 
inflammation is limited to the mucous membrane, the 
term urethritis mucosae given to it by Oberlaender, is an 
appropriate one. These infiltrations do not produce 
any appreciable narrowing of the urethra. Any abnor- 
mal obstruction to the introduction of the urethroscopic 
tube would, therefore, exclude the case from this group 
of infiltrations, unless the obstruction could be explained 
away by faulty technic. 



46 TREATMENT OF GONORRHEA. 

The soft infiltrations are localized in parts that con- 
tain many longitudinal folds, especially in the pars pen- 
dulosa, less frequently in the bulb. Usually the proc- 
ess attacks the more dense mucous membranes, and 
it is of short duration. The intensity of the red color 
is increased. The pale red of an anemic mucous mem- 
brane is changed to a bright rose color; the red of the 
normal mucosa is changed to a bright red, and the 
hyperemic mucous membrane changes to a dark red 
color. 

The epithelial covering is more brilliant than nor- 
mally, and in the most prominent parts of the swollen 
longitudinal fold, and in parts of predilection may be 
seen a slight scaling of the epithelium or a superficial 
degeneration. These spots are lusterless and bleed 
easily. 

The crypts of Morgagni appear as pinhead projec- 
tions, whose color varies from red to deep red, depending 
on the acuteness of the infiltration. The excretory 
duct either is wide open with a crater-like opening and 
swollen, overhanging edges, and a more or less puru- 
lent secretion discharging from its lumen, or the latter 
is closed and the crypts then project more prominently. 

The glands of Littre are affected little or not at all 
in this group of infiltrations. If they are prominent, the 
case must be relegated to the group of hard infiltrations. 
Most of the urethroscopic changes occur in the longitu- 
dinal folds and striae, and can be observed best at the 
borderline between the diseased and the healthy area. 
When there is pronounced swelling, the striae disappear, 



VARIETIES OF GONORRHEA. 47 

while when the swelling is a slight one, the striae are more 
pronounced than in health. 

The longitudinal folds change their order and each 
fold is thicker than normal. There are only about 
half as many folds as are seen in the normal urethra; 
that is, three to four. The color of these folds is a deep 
red, and the appearance of the tissue conveys the impres- 
sion of sponginess, and a smooth surface. In a urethra 
which normally contains but few folds, the folds may be 
obliterated entirely. The central field is always closed. 

The clinical picture just drawn can be seen in cases of 
average severity in from six to eight weeks after the ap- 
pearance of the first symptoms of an infection. It hap- 
pens quite frequently, too, that widespread, apparently 
soft infiltrations have for their nucleus a small mass 
of hard infiltration, which shows on the surface and 
betrays the true nature of the affection after the sur- 
rounding soft infiltrations have been absorbed as the 
result of two or three dilatations done for therapeutic 
purposes. Oberlaender calls these mixed infiltrations. 
They belong to the infiltrations of the second group. 

Soft infiltrations of the posterior urethra are produced 
by urinary sediments (uric acid, phosphates), by sexual 
excesses, and usually by masturbation. They also 
accompany tuberculosis of the genital tract and atony 
of the bladder, with residual urine. But the most com- 
mon cause of this condition is gonorrhea. If any remains 
of the gonorrheal infection are found in the anterior 
urethra, there can be no doubt about the nature of the 
affection in the posterior urethra. 



48 TREATMENT OF GONORRHEA. 

The examination of the posterior urethra may be 
omitted in cases of suspected tuberculosis and in senile 
hypertrophy of the prostate gland. In inflammations 
produced by urinary sediments, the tissues around the 
internal sphincter and the prostatic urethra are especi- 
ally affected, while in inflammations produced by the 
gonorrheal infection, the process spreads more or less 
evenly over the entire posterior urethra, although the 
membranous portion, as the portal of entrance of infec- 
tion, is affected more severely. If there exist reasons 
for believing that the inflammation is the result of ex- 
cesses, the colliculus seminalis should be examined very 
carefully. Under these conditions the membranous 
urethra remains normal. In soft infiltrations the color 
of the mucous membrane is a deep red to blue red. The 
epithelial surface is faintly glistening. The external 
orifice is a dark red to red-brown, and its borders are 
swollen, uneven, even nodular. The colliculus is prom- 
inent throughout its whole length, and in large speci- 
mens it is possible to recognize distinct nodules and fur- 
rows. The openings of the sexual glands, the prostatic 
and ejaculatory ducts and the sinus pocularis have 
gaping mouths and swollen lips. In these cases the 
point of the urethroscopic tube should be held as much 
as possible toward the upper wall, while the tube is 
introduced, and as soon as the point meets with an 
obstruction, it should be withdrawn a little and lifted 
over the colliculus. Such conditions as fullness of the 
rectum or slight spasm of the sphincter urethrae will 
make it difficult to pass this obstruction, and therefore 



VARIETIES OF GONORRHEA. 49 

no effort should be made to complete the examination 
in one sitting. 

The soft infiltrations in the posterior urethra bleed 
very easily, but they also heal very quickly in many 
instances. This is seen particularly in the case of the 
pure gonorrheal infections, where in the course of a 
few weeks complete restitution may take place. In the 
case of the soft infiltrations that are caused by urinary 
sediments, the healing is dependent entirely on the con- 
dition of the urinary tract. In the urethritis due to 
excesses, the return to the normal of the colliculus 
seminalis does not take place so soon, because, as a 
rule, the habits that have caused the condition are 
persisted in. 

The pars membranacea is the first to regain its normal 
appearance, and the pars prostatica comes next. The 
colliculus improves quickly at first, and regains its 
normal appearance to a certain extent, but it is con- 
gested for a long time. This is true, especially, when a 
chronic prostatitis or an inflammation of the seminal 
passages coexists. How and when a relapse takes place 
must be judged from the etiologic and clinical condi- 
tions. The slightest vestige of a gonorrheal infection 
in the anterior urethra may at any time cause a relapse 
of the condition in the posterior urethra. 

The length of time in which a soft infiltration can 
be produced also is dependent on the etiologic factors 
operative in the case. Gonorrheal infiltrations often 
appear within a few weeks or days, and under certain 
conditions they disappear just as quickly. The chronic 



50 TREATMENT OF GONORRHEA. 

irritation of the mucous membrane that is due to the 
urinary sediments does not manifest itself for several 
months ; whereas the infiltration of the colliculus semina- 
lis due to excesses follows after years of intense irrita- 
tion. In these cases the retrogressive changes occur 
much more slowly than in the cases caused by gonorrhea. 

HARD INFILTRATIONS. 

The characteristic feature of this group of inflam- 
mations is their persistence. This is due to the exces- 
sive production of connective tissue in what otherwise 
are cellular infiltrations. This feature is not so notice- 
able in the hard infiltrations of the first degree as it is 
in those of the second and third degrees. The latter 
are perceptible to the fingers as soon as the urethroscopic 
tube is introduced. 

The central field is more or less gaping. The inflam- 
matory patches are distributed irregularly, both on the 
surface of the membrane and in the depths of the ure- 
thral tissue. The favorite location of the hard infiltra- 
tion is the middle portion of the pendulous and all of 
the bulbous urethra. 

Another objective symptom manifested by all degrees 
of hard infiltrations is the " transient scar." 

Hard Infiltrations of the First Degree. — This is 
the first group in which the glandular infection is prom- 
inent, and for the sake of clearness it is necessary to 
describe these infiltrations under separate heads. 

a. The glandular or moist inflammation shows the 
mouth of the diseased excretory duct of Littre's gland 



VARIETIES OF GONORRHEA. 51 

raised above the surface of the mucous membrane. 
The longitudinal striae are absent in all of these ure- 
thras, and the longitudinal folds are absent in the nar- 
row and anemic urethras. In the large and capacious 
urethras, where the folds are numerous, these lesions 
cause a diminution in the number of longitudinal folds 
as well as a change in their size and shape. Instead of 
there being from eight to twelve small, smooth folds, 
the funnel shows only about four to six coarse folds. 
The color of the affected area is paler than that of the 
healthy parts. This is a pathognomonic sign, one that 
is distinctly marked at the borderline of the healthy 
and the diseased mucosa. The color changes from a 
healthy-looking pale red to a very light gray, and from 
a healthy-looking deep red to an unhealthy-looking pale 
red. 

At the height of the inflammation the epithelium 
is desquamating, the process being most pronounced 
in the most infiltrated parts, and in the neighborhood 
of the affected excretory ducts of the glands. Opales- 
cent spots of pachydermia are often found. The sur- 
face in general is slightly glistening. The crypts of 
Morgagni appear as small red projections, and the 
glands of Littre are recognized by the vividly colored 
borders of their excretory ducts. They occupy the 
center of the infiltrated patches. During the process 
of absorption or retrogressive healing the striae may re- 
appear. The longitudinal folds of the wide urethras 
show a division, but the new folds are short, their 
course is interrupted by unabsorbed patches of infiltra- 



52 TREATMENT OF GONORRHEA. 

tion, or the latter may divert the folds from their longit- 
udinal course, often to such an extent as to bring them 
at right angles to the long axis of the urethra. Narrow 
and anemic urethras show the same changes as do the 
wider ones, but the changes are not so distinctive. 

The changes in the epithelial covering furnish the 
best guides on which to base an opinion as to the stage 
of absorption. The opalescent nests of pachydermia 
disappear first, next the desquamation ceases, and, 
finally, the faint glistening appearance of the cells gives 
way to the brilliancy seen in a normal urethra. 

Small stellate scars, or scars circular in outline, are 
usually seen in the surrounding glands, but they rarely 
persist to the stage of complete healing, because they 
are still interpersed with numerous nests of cellular 
elements, and therefore cannot resist absorption. The 
retrogressive healing always is irregular on account of 
the patchy character of the affection. The crypts and 
glands lose their red color and regain their usual appear- 
ance, but disappear either by atrophy or they are covered 
over with a layer of scar tissue. 

b. The follicular or dry infiltrations do not cause 
the excretory ducts to project on the surface of the 
mucous membrane. The affection of the glands is 
hidden from view. The dry infiltrations are found 
in cases which have not been subjected to instrumental 
treatment. The longitudinal striae disappear and the 
longitudinal folds are obliterated, even in wide urethras. 
The color of the mucous membrane varies according 
to the blood supply from a pale rose to a yellow-gray. 



VARIETIES OF GONORRHEA. 53 

Anemic membranes have a waxy appearance. The 
color is more uniform than in the case of the glandular 
infiltrations. 

The epithelium is in an advanced stage of desquama- 
tion, especially at the height of the affection. In the 
urethras, which have not been cocainized, large amounts 
can sometimes be found. Oberlaender has given to this 
form the name of urethritis sicca prolijerans. During 
the process of healing both the longitudinal striae and 
folds are slower to return than in the glandular infiltra- 
tions. The masses of infiltrations are larger than in 
the glandular variety. Hence, more time is required 
for their absorption, and as the healthy normal color 
appears only after complete absorption has taken 
place, the urethra does not resume its normal appear- 
ance for a long time. 

The desquamation of the epithelium soon yields to 
the dilatation, but the faint luster and the unevenness of 
the surface remain for some time. Great attention 
should be paid to the appearance of the epithelium, 
and the case must not be considered as cured until there 
is a uniformly brilliant surface of the mucous membrane. 
The onset of a relapse is manifested by the loss of bril- 
liancy which appears some time before any clinical 
evidence is detected. 

Connective tissue is found in small bundles surround- 
ing the glands and crypts, and on account of its greater 
bulk it is more persistent in this than in the glandular 
form. Graduated dilatation treatment dissolves the 
covering of the glands, and the excretory ducts appear 

5 



54 TREATMENT OF GONORRHEA. 

on the surface. In some cases the dilatation stimu- 
lates the secretion of the still covered glands, the cover- 
ing of the excretory duct is pushed into the lumen of 
the urethra, and appears in the urethroscope as a trans- 
parent vesicle of pinhead size which breaks and dis- 
appears after a while. The subsequent retrogressive 
healing is the same as described in the glandular form. 

Hard infiltrations of the first degree may be found 
from several months to one year after the infection 
has occurred. Discharge of pus from the external 
meatus or the presence of filaments in the urine may or 
may not occur in these cases. 

Hard Infiltrations of the Second Degree. — This 
stage of gonorrhea includes the largest number of cases 
of chronic gonorrhea. The urethroscopic findings 
are identical with those of the nrst degree, but they 
are more marked. 

a. In the glandular or moist infiltrations the long- 
itudinal striae are absent. The longitudinal folds are 
obliterated even in the wide urethras, except at the 
borderline of the patches. In some cases no attempt 
at the production of a funnel can be seen. The urethra 
has the appearance of a stiff tube in a portion of its ex- 
tent, but after passing the narrowest portion of the 
urethra, the urethroscope moves with ease, and some 
attempts at the production of folds are noted. These 
folds generally occur irregularly and may take a trans- 
verse direction. Then there may be seen folds ar- 
ranged regularly but coarse in form. 

The color is paler than in the infiltrations of the 



VARIETIES OF GONORRHEA. 55 

first degree on account of the greater bulk of the de- 
posited masses of connective tissue. The epithelium 
shows all stages of change, depending on the nature of 
the affection in the underlying mucosa. 

The crypts and glands °re affected in the same way 
as they are in the infiltrations of the first degree, but 
there is more connective tissue formation in and around 
the affected structures. The mucosa itself shows scars 
of varying size, usually presenting a net-like arrange- 
ment. Here and there may be seen patches of granu- 
lation. 

More time is required by the process of healing 
in this stage than in the infiltrations of the first degree. 
Its appearance is manifested by the reappearance of 
the longitudinal folds, and the gradual return of the 
normal color and the uniform brilliancy of the epithe- 
lium. All the changes which appear here have been 
described under the infiltrations of the first degree, 
but the connective tissue is produced in larger masses of 
greater density, and is therefore more resistant against 
absorption. Besides, its deposition is not limited to 
the surroundings of the glands, but is found through- 
out the mucous membrane. 

b. The follicular or dry infiltrations. The urethro- 
scopic picture fails to reveal folds and striae. The 
color of the tissues varies from a uniform yellowish-red 
to a grayish- red. In the non-cocainized urethra through 
which no urine has passed for some time, there are often 
found loose, thick, brittle masses of epithelium. Glands 
and crypts are seldom seen on the surface. The 



56 TREATMENT OF GONORRHEA. 

healing of the patches is irregular. The two spots 
which are the slowest to heal are the posterior portion 
of the pendulous urethra on the sides towards the cor- 
pora cavernosa, and in all of the bulbous sac. In both 
these places the infiltration extends, sometimes away 
into the erectile tissues. 

After the patient has been receiving instrumental 
treatment for some time, the urethroscopic picture may 
appear to be a normal one, when on further dilatation a 
deeply located area of infiltration is acted on and the 
result is a relapse. Relapses, therefore, are not only 
unavoidable, but they are the natural result of the 
rational treatment of any form of chronic gonorrhea 
in which the deeper parts of the tissues are involved. 
The relapse can be detected by means of the urethro- 
scope before any clinical evidence is manifested. The 
epithelial surface loses its luster, it is pale, and the long- 
itudinal striae and folds disappear. When the relapse 
occurs in the pendulous urethra, the upper half of the 
funnel is obliterated by the mucosa being stretched 
straight across the opening of the urethroscopic tube. 

At least three or four months are required for the 
development of a case of hard infiltration of the second 
degree, but if left alone after once it is started, its 
progression is practically without any limit. The 
lesion may still be increasing after the lapse of years, 
and in some cases it may be increased in severity by 
unsuitable instrumental treatment. During all this 
time there may be no secretion coming from the meatus 
or threads appearing in the urine. There is no definite 



VARIETIES OF GONORRHEA. 57 

rule about this, but the infective nature of the case re- 
mains undiminished. The narrowing of the anterior 
urethra which is produced by these changes does not 
necessarily cause any disturbance in the voiding of the 
urine. This latter depends more particularly on the 
degree of affection of the posterior urethra and the 
prostate. 

Hard Infiltrations of the Third Degree. — These in- 
filtrations correspond to what is known clinically as a 
stricture. A urethroscopic examination can be made 
in these cases as soon as a bougie of No. 23 Charriere 
will pass the stricture. The tube of 21 Charriere will 
then pass easily. It will reveal the exact position, the 
number and the general conditions of the infiltrations 
present. Sometimes the tube enters to just about the 
middle of the strongest infiltration, when its farther 
introduction is made impossible by the presence of a 
compact mass of infiltrated tissue stretching across the 
lumen of the urethra. After a few more attempts at 
dilatation, the obstruction usually can be passed. 

The urethroscopic picture of these infiltrations 
does not differ from that presented by the hard in- 
filtrations of the second degree. As a rule, from three 
to four months or even several years must elapse be- 
fore the formation of the stricture. In the pendulous 
urethra the infiltrations are always more extensive 
than is at first apparent. The entire anterior urethra, 
beginning behind the glans penis and ending with the 
bulb, usually is affected. The greatest narrowing is 
found about midway between the glans and the bulb. 



58 TREATMENT OF GONORRHEA. 

The striae and the folds are affected as in the in- 
filtrations of lesser degree. The tissue is pale and it 
has a patchy distribution in the glandular areas, is very 
pale, and spread uniformly in the follicular form. The 
epithelium exhibits all degrees of changes from a slightly 
changed luster to a pachydermic appearance. The fun- 
nel is either absent entirely or its central field is disfig- 
ured. The examining tube must be withdrawn very 
slowly because the narrowing parts slip quickly from 
under the tube. The scars may not be seen to their full 
extent in the first examination. The urethroscopic pic- 
ture therefore changes continuously during the course 
of the treatment. 

Folds gradually begin to appear, at first short and 
coarse, and interrupted by the remaining hard infiltra- 
tion. More time is required for the absorption of the 
dry form of stricture than for the absorption of the 
glandular form, because the masses of connective tissue 
are of greater bulk. 

Before a case of stricture is ready to be discharged, 
the following endoscopic conditions must be present. 
The largest urethroscopic tube which will easily pass 
the meatus should meet with no resistance in the ante- 
rior urethra. The largest part of the cavernous portion 
of the urethra should show normal folds, and the mu- 
cous membrane at the site of the stricture should appear 
loose. The circulation must be good, imparting a 
fresh color to the mucosa. It is not possible to restore 
to the epithelium its normal brilliancy in every case, 
but it should not have the appearance either of dryness 



VARIETIES OF GONORRHEA. 59 

or scaliness. The scars should appear as clean whit- 
ish streaks or points located subepithelially, and should 
not show any sloughing. The tissue around the glands 
should not show any evidence of irritation. 

Relapses are the rule, and not the exception in these 
cases. They usually appear within the area of the 
old affection. But this is not always the case, especi- 
ally in recent infections, those not over one year old. 
The new swollen part may be in front of or behind the 
location of the old infiltration. The urethroscopic 
picture of the relapse varies. It may have the appear- 
ance of a picture seen at the beginning of the first dila- 
tation, or that seen during the last third or quarter of 
the period of healing. 

The hard infiltrations of the posterior urethra re- 
semble those of the anterior urethra, but they do not 
show as great a variation. The membranous portion 
histologically stands nearer to the anterior urethra than 
does the prostatic portion, and pathologic changes 
seen here therefore resemble more those met with in 
the anterior urethra than in the remainder of the pos- 
terior urethra. 

Gonorrhea is the most frequent etiologic factor 
in the production of hard infiltrations, but sexual ex- 
cesses, mostly masturbation, may produce a hard in- 
filtration of the colliculus seminalis and of the excre- 
tory ducts of the sexual glands, one which resembles 
very much the infiltration caused by gonorrhea. 

The division of the hard infiltration into a glandular 
and a follicular form is not as marked here as in the an- 



60 TREATMENT OF GONORRHEA. 

terior urethra. In the hard infiltrations of the first 
degree the membranous urethra is pale red, and has 
a dead, glistening surface. The colliculus is lower 
than normal, and has a pale yellow or greenish-white 
color, a distinctly dry look, and not showing any fur- 
rows. The openings of the sexual glands are small, 
not gaping, and have only a slightly reddened border. 

In the hard infiltrations of the second degree it is 
always necessary to dilate for some time before a success- 
ful urethroscopic examination can be made of the pos- 
terior urethra. If a sound of No. 25 Charriere enters 
the bladder, a successful examination can be made 
with tube o, No. 23 Charriere. The urethroscope 
reveals the same picture as is seen in the case of in- 
filtrations of the same degree in the anterior urethra. 
A long course of dilatation may be necessary in the case 
of these hard infiltrations before a successful endoscopic 
examination can be made. After entering the poste- 
rior urethra, the tube often is obstructed by infiltrations 
deposited around the tube circularly. The urethro- 
scopic picture is identical with that seen in the ante- 
rior urethra. In some cases the newly-formed tissue 
is one with the surrounding tissue. The lumen of the 
urethra is distorted, thus preventing a satisfactory 
urethroscopic examination. 

As to the healing, the same holds true here as in 
the case of the same affection in the anterior urethra. 
The scars gradually separate into smaller linear ones. 
The surface regains its luster and there may be some 
attempts made at the formation of a funnel. The collie- 



VARIETIES OF GONORRHEA. 61 

ulus usually retains its flat and depressed form. Re- 
lapses are the rule in most cases. 

The time necessary for the production of hard in^ 
filtrations in the posterior urethra varies considerably. 
Infiltrations of the colliculus without gonorrheal in- 
fection may not occur until after years of continued 
excessive sexual irritation. Hard infiltrations of slight 
degree and due to gonorrheal infection may be expected 
to form within a year from the occurrence of the infec- 
tion. At least several years are required for the for- 
mation of a stricture. 

In some instances the gonorrheal infection of the 
posterior urethra is accompanied by the formation of 
abscesses. Oberlaender describes inflammations under 
a separate heading. He has found that these abscesses 
occur only in the cases of mixed infection, when the 
condition of the mucous membrane is bad, and in cer- 
tain individuals who possess a natural predisposition 
to chronic catarrhs and to tuberculosis. Oberlaender's 
investigations on the cadaver show that abscess form- 
ation very often occurs in persons who are affected with 
phthisis, but who do not show any tubercular lesions in 
the genitourinary tract. 

A urethroscopic examination is seldom possible dur- 
ing the formation of abscesses, because of their acute 
course. The clinical symptoms are those of a more or 
less painful posterior gonorrheal urethritis of long 
standing. 

The sequelae of this affection are scarry strictures; 
there is no narrowing of the anterior urethra nor of the 



62 TREATMENT OF GONORRHEA. 

remaining portion of the posterior urethra. With the 
exercise of patience, it is possible to restore the lumen of 
the urethra to its natural size and form. The urethro- 
scope shows linear and star-shaped scars. 

All affections of the posterior urethra often are 
accompanied by similar affections of the seminal ves- 
icles and the prostate gland, but the severity of these 
lesions is not interdependent. A common soft infil- 
tration which yields readily to suitable treatment may 
be accompanied by a very obstinate funiculitis or pros- 
tatitis, and vice versa. 

As to the location of the disease, it may be said that, 
as a rule, the entire posterior urethra is affected, but not 
in the same degree in all its parts. A hard infiltration 
of the membranous urethra may be accompanied by a 
soft infiltration in other parts of the posterior urethra. 
THE CHANGES OF THE EPITHELIUM. 

The changes in the epithelial covering are important, 
from the standpoint of diagnosis. It is therefore neces- 
sary as well as advisable to discuss them separately. 
Normally, the epithelium is smooth and moist, trans- 
parent, and of a uniform color. Its natural brilliancy 
may be enhanced by the presence of mucus, remains of 
glycerine and cocaine, and also pathologically, when 
there are present slight forms of soft infiltrations. 

Diseased conditions as a rule do not increase its brilli- 
ancy ; on the contrary, they cause it to disappear. Long- 
standing irritations produce disturbances in the nutrition 
of the epithelial covering which lead either to its com- 
plete destruction or to its degeneration into pavement 



VARIETIES OF GONORRHEA. 63 

epithelium. In slight forms of infiltrations the diseased 
membrane assumes a lusterless appearance, although 
its surface remains smooth. In an anemic mucous 
membrane, slight disturbances in nutrition may not be 
noticed. The color is normal, but capillary networks 
may develop in the longitudinal folds. These networks 
are observed through the urethroscope as small ele- 
vations usually denuded of epithelium. Then, too, 
small areas of granulation bleed easily if they are 
touched with the tube during the examination. 

In the hard infiltrations of the mucous membrane, 
the disturbance of nutrition is more marked than in 
the soft infiltrations. The epithelium loses its trans- 
lucent appearance and its surface is less smooth than 
normally, due to the desquamation and irregular repro- 
duction of the cell layers. A careful urethroscopic 
examination reveals quite a number of small irregular 
elevations, which rarely ever bleed. 

As the process continues, the desquamation is accom- 
panied by an overgrowth of epithelium in the most 
diseased spots ; the elevations now measure one or more 
millimeters in height, and bleed easily. The surface 
of the affected part shows a loss of substance. A con- 
tinuance of the process may cause spots of pachydermic 
change in the epithelium, or this change may be uni- 
form throughout. The epithelium has a pale grayish 
color; its surface is irregular, and shining through it, 
here and there, may be seen the red color of the under- 
lying mucosa. This imparts to the mucous membrane 
an appearance like that of being covered by a veil. 



64 TREATMENT OF GONORRHEA. 

In cases treated by injections, Oberlaender found that 
when zinc salts come in contact with the mucous mem- 
brane while it is in the stage of soft infiltration, small 
white crusts may be produced, and these remain for 
several weeks after stopping the use of the zinc salt. 
So, too, resorcin, in strong solution, may cause great 
swelling and cornification of the epithelium, similar to 
the effect seen in the skin after applying a strong solu- 
tion to it. Silver nitrate used for a short time imparts to 
the mucous membrane an even, whitish look, as though 
it were covered with white crust. The shaving off of 
these crusts may take place within a few hours or days 
after the last treatment. The continued use of the 
silver produces the condition known as argyrosis, stain- 
ing the mucous membrane as it does the skin. The 
discoloration appears in the form of bluish-black spots, 
which are found mostly in the bulb and in the neigh- 
boring parts of the shaft. They seem to follow the 
longitudinal fold. The discoloration is most apparent 
in mucous membranes rich in blood supply. Dark 
discolored rings are often found surrounding .inflamed 
glands and crypts. This is caused by the staining of the 
epithelial overgrowth in these tissues. The argyrosis 
of the urethral mucous membrane may persist for years 
without apparently interfering in any way with the well- 
being of the patient. 

A pure epithelial abnormality is psoriasis mucoscb 
(Oberlaender). This condition, occurring either with or 
without the incentive of a chronic gonorrhea, consists of 
irregular, semi-circular or spherical white spots. These 



VARIETIES OF GONORRHEA. 65 

spots are very thin and transparent in the center, but 
become more dense at the periphery. They do not 
project above the surface of the mucous membrane. 
They are not due to proliferation of tissue. Their 
etiology is not definitely known. Kollmann showed 
that the epithelium covering these spots was of the 
pavement variety. 



CHAPTER V. 
PROGNOSIS OF ACUTE AND CHRONIC GONORRHEA. 

In pure gonorrheal affections of the urethra, the 
prognosis is good. In the subacute and chronic cases 
the prognosis depends on the nature of the infiltrations, 
the duration of the case, the severity of the complica- 
tions, and the treatment instituted. Illy-conducted 
instrumental treatment may retard the healing for a 
long time. The age of the patient is of no significance, 
but the duration of the disease plays an important part 
in the retrogressive process of healing. A case of only 
three or four years' standing will give a better prognosis, 
so far as complete healing is concerned, than one of 
longer duration, ten to twenty years. In the latter 
case, a very careful diagnosis must be made and the re- 
actions following the treatments must be noted with 
precision. An opinion as to the duration of the treat- 
ment necessary should be expressed with reserve. 

On the other hand, it is wrong to make a bad prog- 
nosis, even in the case of old and apparently stubborn 
cases without having first made every possible attempt 
to produce a cure. In cases that have been over- 
treated, it is advisable to stop the use of instruments 
and to keep the patient on internal medication (bal- 
samics, urotropin) for several months. 

No method of treatment will prevent the occurrence 

66 



PROGNOSIS OF GONORRHEA. 67 

of relapses. They are determined by the pathology of 
the condition, and consequently form a regular part of 
the treatment. Our method enables us to see the ob- 
jective evidences before any clinical symptoms are man- 
ifested. Suitable treatment can, therefore, be instituted 
early and the severity of the relapse diminished. 

It is difficult to estimate the length of time required 
for treatment in any case, but there are certain points 
which can be determined by urethroscopic examination 
and by means of which we may guard against making 
any gross errors. The soft infiltrations seen in the sub- 
acute cases and in the healing stage in the acute cases 
offer the best prognosis. These cases usually heal 
within three to six weeks. In the hard infiltrations, 
even those of slight degree, the prognosis is less certain 
and less favorable. This stage of chronic gonorrhea 
requires longer treatment, and is more often accom- 
panied by complications. As a rule, the treatment 
must be continued for as many weeks as the disease has 
existed months. In the case of the infiltrations of the 
worst degree, no prediction should be made as to the 
possible duration of the treatment until the case has 
been under observation for some time and has shown a 
tendency to decided and steady inprovement. This 
must be verified by urethroscopic examination. The 
lessening and cessation of the secretion, the disappear- 
ance of filaments from the urine, and the amelioration of 
the subjective symptoms and signs are taken by the 
patient and by the inexperienced physician to mean the 
beginning of the healing process. Provided that the 



68 TREATMENT OF GONORRHEA. 

urethroscope examination shows the process of healing 
to be a satisfactory one, we can tell the patient that one- 
half to three-fourths of the time that has passed since 
the last infection will elapse before a cure may take 
place. 

Other factors which have a disturbing influence on 
the process of healing are a poor condition of the mu- 
cous membrane, chronic catarrhal inflammations in 
other parts of the body, alcoholism, bicycling, impure 
sexual intercourse, complications and mixed infections. 
In certain conditions it is advisable to confine one's 
self to symptomatic treatment, or no treatment at all, 
as, for instance, in cases of heart disease, progressive 
tuberculosis of the lung, grave luetic affections, especi- 
ally lues of the nervous system, severe forms of dia- 
betes, and of neurasthenia (not sexual neurasthenia), 
diseases of the kidneys if there does not exist a causal 
relationship between the kidney affection and the chronic 
gonorrhea. 

The pronounced clinical symptoms of a gonorrheal 
complication usually begin and end with the acute stage. 
It is of the greatest importance, however, first to treat 
the underlying condition, although any active treat- 
ment of the gonorrhea itself will increase the severity 
of the complication. 

The course to be pursued in these cases depends in 
great part on the experience and skill of the physician. 

Of substances whose ingestion should be avoided, 
the following may be named: Alcohol and some fer- 
mented, non-alcoholic substances contained in recently 



PROGNOSIS OF GONORRHEA. 69 

brewed beer and in wines, spices, such as pepper, onions 
and the so-called English sauces. Recent observations 
seem to show that the above-named substances reduce 
the opsonic index and injure the patient more by re- 
ducing his resistance than by the production of an 
irritating urine. Coitus should be prohibited absolutely, 
although some clinicians permit its occasional practice 
when a condom is used. 



CHAPTER VI. 

INSTRUMENTS USED IN THE TREATMENT OF GON- 
ORRHEAL INFILTRATIONS. 

For the sake of thoroughness and a better under- 
standing of the instrumental treatment of gonorrhea, 
it is well to describe the instruments employed before 
the treatment itself is taken up. These instruments 
may be of metallic construction, when they are non- 
elastic, or of non-metallic construction, when they are 
elastic. The metallic instruments consist of catheters, 
sounds and dilators. 

A very important part of every instrument is its 
curve. Therefore, we will describe briefly the most 
important curves employed. 

Dittel recommends three curves, the short, the middle 
and the long. The short curve (Fig. 13) represents 
the segment of a circle 9 centimeters in diameter. 
The point of the curve ends 30 millimeters from the 
elongation of the longitudinal axis. The middle curve 
(Fig. 14) represents the segment of a circle, 10.8 cen- 
timeters in diameter, the point of the curve ending 40 
millimeters from the elongation of the longitudinal axis. 
The long curve (Fig. 15) represents the segment of a 
circle, 13.8 centimeters in diameter, and its point ends 
58 centimeters from the elongation of the longitudinal 
axis. In the Guyon-Thompson stone searcher (Fig. 16) 

70 



INSTRUMENTS USED IN THE TREATMENT. 71 



307TL7TL 

r 




\ 69711m t IG . 15. 



\ 






72 TREATMENT OF GONORRHEA. 

the curve is knee-shaped or in the form of a hook. 

This instrument is particularly useful in those cases 
where instruments having the ordinary curve 
can be made to enter the posterior urethra 
with difficulty. In the majority of cases it 
does not matter which instrument is used, 
but the most convenient is that having a 
short curve and representing one-fourth of 
the segment of the circle. It is advisable, 
however, to have on hand the variously-curved 
instruments. 

The metallic catheters ought to be made 
of hard silver, but if expense is an item, the 
instruments can be made of German silver 
nickel-plated. 

The catheter should not be less than 28 to 
30 centimeters (11 to 12 inches) long. Dittel 
recommends the use of 14 Charriere catheters 
for dilating strictures rather than the sounds, 
because the former are lighter in weight and 
less prone to injure the urethra than the solid 
instruments. 

Some metallic catheters are made exclu- 
sively for irrigating purposes, such as the irri- 

Fig. 16. gating catheters of Oberlaender, of which 

Guy on- there are two forms (Figs. 17 and 18), both of 

Thomp- \ o 1 ^ /> 

son stone- which are used in the anterior urethra only. 

The former consists of a silver tube, 15 cms. 

(6 inches) long, having a slight bend at its distal end, in 

which are seen several rows of small perforations. It is 




INSTRUMENTS USED IN THE TREATMENT. 73 

manufactured in sizes of 14 to 20 Charriere; the latter 
is a straight tube, 15 cms. long, and about 15 Charriere 
size. Its distal end is provided with a thread for the 
purpose of attaching a head corresponding to the size 



Fig. 17. 

of the urethra or the caliber of the meatus. These 
heads range in size from 18 to 24 Charriere. In the 
tube below the head are several rows of perforations 
through which the irrigating fluid passes. 




Fig. 18. 



An instrument used extensively for irrigating the pos- 
terior urethra is the curved injector of Ultzmann, modi- 
fied by Oberlaender (Fig. 19). It consists of a metal 
tube, 20 cms. (8 inches) long, and 15 Charriere in 




Fig. 19. — Oberlaender-Ultzmann injector. 

diameter. The distal end of this tube is provided 
with numerous small perforations, which facilitate the 
application of medicaments. 

The instillator (Fig. 20) also was devised by Ultz- 



74 TREATMENT OF GONORRHEA. 

mann. It consists of a capillary catheter to which is 
attached a small syringe. It is used for the purpose of 
depositing small quantities of strong nitrate of silver 
solution on the urethral mucous membrane. The in- 
strument should not be used because, first, this method of 




Fig. 20. — Ultzmann instillator. 




treatment is irrational so far as the pathology of gonor- 
rheal infiltrations is concerned, and, second, the appli- 
cations can be made far more satisfactorily by means of a 
Guyon perforated explorator (Fig. 21). 

The straight metal sounds are used exclusively for 




Fig. 21. — Guyon perforated explorateur. 

the treatment of the anterior urethra, while the curved 
sounds are used for the treatment of the posterior ure- 
thra and for examination of the bladder. The straight 
sounds (Fig. 22) used by Oberlaender and Kollmann 
are somewhat conical in shape, the difference between 



INSTRUMENTS USED IN THE TREATMENT. 75 

the largest and the smallest part averaging two Char- 
riere. The shaft is 15 cms. (6 inches) long. The han- 
dle consists of a metal plate on which is stamped the 
size of the instrument. The largest part of the sound 
designates its size. 



Fig. 22. — Sound for anterior urethra. 



V. 



.V 



Fig. 23. — Sound with short Dittel curve. 



1 - m<***mm, Baa— ^— M"ir< -"itwti 

Fig. 24. — Sound with long Dittel curve. 




Fig. 25. — Sound with Guyon curve. 

The curved sounds are also slightly conical, the dif- 
ference between the smallest and the largest diameter 
averaging two to three numbers of Charriere. The 
sounds used most often are shown in Figs. 23 and 24. 

A sound of special value in cases of hypertrophy of 
the prostate, on account of the pressure it exerts on the 
colliculus seminalis and on the ends of the prostatic 
and ejaculatory ducts, is Guyon's modification of 
Benique's sound (Fig. 25). The curve of this sound, 



76 TREATMENT OF GONORRHEA. 

as manufactured to-day, represents one-third of the 
circumference of the circle measuring 9.2 cms. (3I 
inches) in diameter. It is cylindrical in shape, and 
from 28 to 30 cms. (11 to 12 inches) long. Of the 
metal sounds, both the straight and the curved, the 
physician should be supplied with all the numbers from 
15 to 30 Charriere. The best material for manufacturing 
these instruments is German silver nickel-plated. The 
steel sounds ordinarily supplied by instrument-makers 
are not so expensive as the German silver sounds, but 
they possess the disadvantage that they corrode very 
easily and lose their smoothness. 

The dilators are metallic instruments which can be 
introduced into the urethra in a closed condition. 
They measure 21 to 25 Charriere, and may be dilated 
up to 45 Charriere, as needed. The dilators take the 
place of the sounds in the treatment of gonorrheal infil- 
trations of slight degree that are situated in those parts 
of the urethra that have a larger caliber than the external 
orifice. A sound effectually dilates the narrowest part 
of the urethra, and is therefore of service only in the 
beginning of the treatment, for the purpose of improving 
the strongest infiltrations and absorbing or healing infil- 
trations situated in narrow parts of the urethra, especi- 
ally around the meatus. For this and for other reasons 
to be mentioned later, it is always advisable to begin the 
treatment by using sounds, changing to the dilators when 
the urethroscopic picture shows that the period of use- 
fulness of the sounds is passed. 

Kollmann advises the use of straight sounds up to 30 



INSTRUMENTS USED IN THE TREATMENT. 77 



Charriere before changing to dilators. Otis, of New 

York, was the first to use dilators in the treatment of 

chronic gonorrhea. While his views on 

the pathology and the treatment of this 

affection are open to question, he was the 

first to take a step in the right direction 

and must, therefore, be regarded as the 

father of the present-day therapeutics of 

chronic gonorrhea. 

Otis devised a two-branch dilator (Fig. 
26) which could also be used as a ureth- 
rotome. It is with this instrument that 
Oberlaender made his first studies, and 
that led to the construction of a modified 
two-branch dilator, to be used in the 
anterior urethra. Oberlaender then de- 
vised instruments of different forms de- 
signed to be used in every part of the 
urethra. 

The mechanical action of the sounds 
consists of tension and pressure. The 
therapeutic action of the dilators consists 
of tension between the branches and pres- 
sure with some tension over the branches. 
It is evident that the more branches a 26.— Otis' 

dilator possesses, the more nearly will its two branch diia- 

r J tor and uretnro- 

therapeutic effects resemble those of the tome. 
sounds. Kollmann's four- branch dilator meets these 
requirements the best. 

At least three varieties of Kollmann's dilators are 




78 



TREATMENT OF GONORRHEA. 



Fig. 27. — 
Dilator for 
the anterior 
urethra. 



Fig. 28. — Dilator for 
the posterior urethra 
and the bulb. (DitteVs 
curve. ) 



Fig. 29. — Dila- 
tor for the pos- 
terior urethra 
and the bulb. 
{Guy on curve.) 



INSTRUMENTS USED IN THE TREATMENT. 79 

necessary to treat the infiltrations of the urethra ration- 
ally: 1. A straight four-branch dilator, to be used 
in the anterior urethra, and having a dilating surface 
of not less than 12 cms. (5 inches) long (Fig. 27). 
2. A dilator with Dittel's or Guyon's curve, which 
dilates only at the curved portion (Figs. 28 and 29). 
The length of the dilating part of the instrument is from 
9 to 10 cms. (4 inches). These dilators are of service 
for dilating the posterior urethra and the bulb. 3. A 
dilator which dilates throughout its entire length, both 
in its curved and in its straight parts, and which can be 
provided either with a Dittel or a Guyon curve. It is 
used to dilate the entire urethra, and in the case of long 
urethrae it may also be used to dilate the bulb only 
(Figs. 30 and 31). 

Formerly it was necessary to cover the dilators with 
rubber caps, so that they could not injure the mucous 
membrane, which they were especially apt to do while 
the instrument is being closed. The newer forms 
of Kollmann's instruments can be used without a pro- 
tector. Fig. 32 shows the difference between the old 
and the new form of construction. In transverse sec- 
tion the old instrument forms a circle when closed, while 
the new instrument shows the branches as separate 
bars, with intervening spaces of large size between 
their peripheral parts. A revolving plate at the handle 
of the instrument indicates the degree of dilatation. 

In order to do efficient work, the operator should be 
supplied with at least three of Kollmann's dilators. 
To be limited to only two, the anterior and the postc- 



8o 



TREATMENT OF GONORRHEA. 






Fig. 30. — Dilator for 
anterior and posterior 
urethra. (DitteVs curve.) 



Fig. 31. — Dilator for 
anterior and posterior 
urethra. (Guyon's curve.) 



INSTRUMENTS USED IN THE TREATMENT. 81 

rior, lengthens the time of treatment. If he is limited 
to the use of only one dilator, he must choose the poste- 
rior, but, of course, the result of the treatment will not 
be very satisfactory. 

For irrigating the mucous membrane while the ure- 
thra is dilated, Kollmann, following the example of 
Lohnstein, constructed dilators with irrigating devices. 
The principle of their construction is the same as that 
of the simple dilator, but they are hollow and serve 
the purpose of a dilator and irrigator. The position 
of the branches is somewhat different, inasmuch as 
the purpose which these instruments serve is not so 
much that of dilatation as irrigation. The dorsal 




and ventral surfaces of the urethral canal must, there- 
fore, not be covered by the dilating branches, as is 
done by the simple dilator. Fig. 33 shows the princi- 
pal forms of Kollmann's irrigating dilators. 

The elastic instruments employed in the treatment 
of gonorrhea are the catheters and the bougies. They 
are constructed of a tightly woven ground substance of 
cotton or silk, or a mixture of both, impregnated with 
a resinous substance. One of the most important of 
these instruments is the Mercier catheter, with single 
(Fig. 34) and double (Fig. 35) curve. They are of 



82 



TREATMENT OF GONORRHEA. 




Fig. S3- — The principal forms of Kollmann's dilating irrigators. 



INSTRUMENTS USED IN THE TREATMENT. 83 



special use in cases of prostatic hypertrophy. Guyon's 
perforated explorator is very well adapted for making 




Fig. 34.— 
Mercier ca- 
theter with 
single curve. 



Fig. 35. — Mercier 
catheter with double 



curve. 



deep urethral instillations. Its lumen, which is of very 
small size, ends in a single opening at the extreme end 
of an olive-shaped head. 



8 4 



TREATMENT OF GONORRHEA. 



Of the elastic sounds or bougies, the cylindrical 
shaped (Fig. 36) and the conical shaped, with and with- 



Fig. 36. 



Fig. 37. 



Fig. 38. 



Fig. 36. — Cylindrical shaped bougie. 

Fig. 37. — Conical shaped bougie with bulbous end. 

Fig. 38. — Conical shaped bougie. 

out bulbous ends (Figs. 37 and 38), are the ones most 
needed. In the beginning of the treatment of a narrow 



INSTRUMENTS USED IN THE TREATMENT. 85 



i> # 



stricture, it is often necessary to make use of the fili- 
form bougie (Fig. 39). 

Now, as to the measurements of the diameters of 
these instruments. The most widely 
known form of measuring is that 
devised by Charriere, a French in- 
strument-maker. Each number of 
his scale represents one-third of a 
millimeter ( T X T inch) in diameter, so 
that No. 30 is one centimeter (f 
inch) in diameter. 

Van Buren and Keyes are the 
originators of the American scale, 
in which each number represents a 
diameter of half a millimeter (^5- 
inch). English measurements are 
not uniform. They are subject to 
change by author and instrument- 
maker. 

Instruments should always be 
sterilized before and after using 
them. The best method of sterili- 
zation is boiling, but it affects elastic 
instruments in time; therefore, it 
may at times be sufficient to disin- 
fect these instruments by immersing 
them in a one promille bichloride 
of mercury solution, or a four per cent, carbolic acid 
solution. The dilators stand boiling very well, but 

they need special care on account of the many little 

7 



Fig. 



39. — Filiform 
bougie. 



86 TREATMENT OF GONORRHEA. 

joints they have, and which break easily after they be- 
come corroded. 

Some authors advise keeping these instruments 

immersed in absolute alcohol when they are not in 
use, but this method is an expensive one. The follow- 
ing method has given me perfect satisfaction. After 
sterilization the dilator is dipped into absolute alcohol 
and is then wrapped up in a sterile towel. The dilator 
is then dried under an electric lamp. 






CHAPTER VII. 

METHOD OF INTRODUCING INSTRUMENTS INTO 
THE URETHRA AND BLADDER. 

The normal urethra has a lumen of very uneven 
caliber. Its narrowest part is at the external orifice, 
so that the latter determines the size of the instrument 
that can be used. Next to the external orifice the isth- 
mus, the beginning of the membranous urethra, is the 
narrowest portion; but its narrowness is not so much 
the cause of difficulty in entering it as is the wideness 
and looseness of the bulbous sac. The wide parts 
of the urethra present difficulties to the introduction of 
instruments much more often than do the narrow por- 
tions. The wide portions of the urethra are the navic- 
ular fossa, the bulbous fossa, and the prostate sinus 
(Dittel). Instruments are introduced into the urethra 
with the patient in the upright, the sitting or the recum- 
bent position. The latter is to be preferred, the hips 
resting on an inelastic support. Before proceeding with 
the introduction of the instrument, it is advisable to 
make a rectal examination, in order to determine 
the size of the prostate gland, because on the length 
of the prostatic urethra depends the position of the 
bladder; that is, whether it is situated high or low in the 
pelvis. The internal urethral orifice may be lifted out 
of the true pelvis when either the bladder or rectum are 

87 



88 TREATMENT OF GONORRHEA. 

full; while the reverse condition will cause the internal 
orifice to descend into the pelvis. The higher the level 
of the internal urethral opening, the more must the 
handle of an inelastic instrument be depressed in order 
that its distal end may be made to pass into the bladder. 

It is advisable to conduct the first examination with- 
out the use of cocaine, because the natural sensitiveness 
of the urethra furnishes a valuable clue as to when the 
introduction of the instrument causes pain. The intro- 
duction of a straight metallic instrument into the ante- 
rior urethra, and of elastic instruments into the urethra 
and bladder, usually is not accompanied by any diffi- 
culties, provided the formation of transverse folds in 
the mucous membrane is prevented by traction which 
will lengthen the urethra and straighten the transverse 
folds. 

The three principal methods of introducing curved 
metal instruments into the urethra and bladder are, 
the "tour over the abdomen," the "great master tour," 
and the "half master tour." 

The first mentioned is the simplest of the three (Fig. 
40). The operator stands at the left of the patient 
and with his right hand holds the instrument parallel 
with the median line. The penis is held just behind the 
corona between the middle and ring fingers of the left 
hand, while the thumb and index finger separate the 
lips of the meatus. The instrument is introduced in 
the direction of the linea alba by pulling the penis over 
the sound, and at the same time allowing the instru- 
ment to advance under the pubic arch by its own weight 



METHOD OF INTRODUCING INSTRUMENTS. 89 

up to the commencement of the bulbous urethra. The 
introduction of the instrument is completed by describ- 
ing the segment of a circle until the shaft of the instru- 
ment stands vertical. The distal end ought now to have 
entered the isthmus, but in some cases this may be pre- 
vented by the existence of a cut de sac. Then, the instru- 




Fig. 40. 

ment is withdrawn slightly, and with the left hand un- 
der the scrotum making slight upward pressure on the 
bulbous sac, the instrument is introduced slowly. When 
its shaft is at an angle of forty-five degrees to the hori- 
zontal line, the distal end of the instrument has passed 
under the pubic arch and is in the prostatic urethra. 
Further lowering of the handle and careful advancement 



go TREATMENT OF GONORRHEA. 

of the instrument until the shaft is in the horizontal 
plane, brings the distal end and more or less of the curve 
of the instrument into the bladder. When the posterior 
urethra is large, and the colliculus seminalis is hyper- 
trophied, the end of the instrument may be caught at 
the base of this prominence. This obstruction is made 
evident the moment the operator attempts to depress 
the instrument more than forty-five degrees. 

Marked bulging of the posterior wall of the prostatic 
urethra (Dittel's prostatic sinus), together with a well- 
developed sphincter muscle may be the cause of another 
obstruction. According to Oberlaender, the point of 
the sound may also be caught in the strongly developed 
muscle fibers of the posterior border of the trigone. 
These various obstructions in the posterior urethra must 
be overcome by withdrawing the instrument slightly 
and then directing its point toward the upper wall of 
the urethra, at the same time making pressure from 
below upward and forward. 

In the so-called great master tour, the physician 
stands to the right of the patient and begins the intro- 
duction of the instrument by holding it in a horizontal 
position between the thighs of the patient. After the 
point of the instrument has entered the bulb, the handle 
is made to describe a spiral over the left thigh, and is 
brought to a vertical position. Meanwhile, the left 
hand presses the instrument slightly against the isthmus. 

In the small master tour the physician stands to the 
left of the patient and commences the introduction of 
the instrument by holding it at a right angle to the long 



METHOD OF INTRODUCING INSTRUMENTS. 91 

axis of the body of the patient. After reaching the bulb, 
a spiral curve will again bring the instrument into a 
vertical position. 

The passage through the posterior urethra is the same 
in the three methods. These methods may be used as 
described, or modified to meet the indications of an 
individual case. Each one of these methods has special 
advantages which can be made use of in difficult cases, 
such, for instance, as false passages, pathologic con- 
ditions limited to one or the other wall of the urethra, 
well-developed panniculus adiposus, and so forth. 

Every instrument of use in the treatment of gonorrhea 
must be sterilized before and after it is used. As 
stated before, the sterilization is effected best by boiling 
for from five to ten minutes in water, to which a little 
sodium bicarbonate has been added. When glycerine 
is used as a lubricant, it should also be boiled before and 
after use. Fatty lubricants are to be used only in excep- 
tional cases, because they are not soluble in water. 



CHAPTER VIII. 
GENERAL CONSIDERATIONS OF TREATMENT. 

The symptoms of a gonorrheal infection of the 
urethra as we see them in our clinical work represent 
the defense of an attacked mucous membrane and not 
the disease per se. What we see is the physiological 
effort of the attacked body to defend and rebuild its in- 
tegrity, but not the attacking enemy. The gonorrheal 
germ and its metabolic products, by their damaging 
irritation, attract the fighting forces of the body to the 
exposed area; hence, we get a congestive hyperemia 
accompanied by suppuration — the useful reaction of an 
infected lesion — swelling and edema. 

Nature does its defending and healing by hyperemia. 
In our effort to assist nature, we must, therefore, try to 
increase the congestion of an inflamed part instead of 
attempting to relieve it, as it has been wrongly advised. 
It is fortunate that Nature usually finds means of turn- 
ing misdirected therapeutical efforts into the right di- 
rection. As we see it, for instance in the application 
of a cold to relieve congestion. Here Nature is gener- 
ally able to respond to the cold by an increased con- 
gestion and in this way make the interference a bene- 
ficial one. 

The treatment of gonorrhea is both medical and 
instrumental. 

92 






GENERAL CONSIDERATIONS OF TREA1MENT. 93 

MEDICAL TREATMENT. 

The medical treatment consists mainly in the use of 
germicidal drugs given internally or applied locally. 

Their theraupetic action can be divided into a direct 
and an indirect. The direct action is limited to the 
parts with which the antiseptic comes in contact, and is 
of purely chemical nature. The indirect action con- 
sists in the production or in the increase of an already 
present congestive hyperemia. The latter is the answer 
of the body to the irritation produced by the antiseptic 
action of the drug applied;* it is also Nature's means 
of limiting and destroying an invading germ. The 
germicidal drugs administered internally in a simple 
infection of gonorrhea are mainly balsamic in nature. 
Their therapeutic action is dependent on the amount 
of resinous acid which they contain (Weikart and 
H. v. Zeissl). In the human body this acid is con- 
verted into a soluble soap by combining with potas- 
sium or sodium. This soap is excreted by the kidneys 
and dissolved in the urine acts as an antiseptic. The 
aromatics contained in these balsams are devoid of 
any therapeutic action, except perhaps to act as stimu- 
lants to digestion. None appear in the urine. 

By far the most active balsam is oil of sandalwood. 
The dose is from 5 to 20 minims, taken three times a 
day, after meals. Taking the sandalwood with the 
meals does not interfere with its therapeutic action. 
Some patients cannot take sandalwood except with 

* We often expect medical, also instrumental, treatment to produce an 
irritation with the intent to stimulate Nature to heal. 



94 TREATMENT OF GONORRHEA. 

meals. When the patient complains of loss of appetite, 
the use of the drug should be discontinued. Pain in 
the back must be regarded as a symptom of kidney 
irritation, even when albumin does not appear in the 
urine. Under such circumstances, it is advisable to 
discontinue the use of the drug entirely. 

The resinous soap is precipitated from the urine by 
nitric acid, and the precipitate may be dissolved by 
alcohol, thus differentiating it from albumin. 

A number of very useful combinations containing 
oil of sandalwood may be had. As a rule, they are 
given in the same dose as the pure oil of sandalwood, 
and they are not markedly inferior in therapeutic 
action; neither do they derange the stomach any less 
than the pure drug. 

The following balsamic emulsion has given me good 
service in these cases: 

1$ Copaibae, 

Tinct. cubebae, 

Spt. aetheris nitrosi, aa Bss. 

Mucilage acaciae, q. s., ad §iv. 

A teaspoonful three to four times a day after meals. 

In mixed infections, especially if accompanied by 
alkaline urine, the following urinary antiseptics are of 
value: 

1$ Salolis, 5ij. 

Aspirin, . . 3 j. 

M. et d. in dos. aeq., xxiv. One four times a day. 

1$ Helmitol, gss. 

Mucilage acaciae.q. s., ad §iv. 

Teaspoonful three to four times a day after meals. 



GENERAL CONSIDERATIONS OF TREATMENT. 95 

1^ Tab. Urotropin, gr. *j\ . 

XV, one, t. i. d. 

^ Caps. Arhovin, gr. iii. 

XXX; one to two, three times a day. 

Internal medication is indicated particularly in cases 
in which there is a marked purulent discharge, but it 
is that part of the treatment which may be omitted. 

Of greater importance than the internal administra- 
tion of drugs is the local application of germicides. 
The principal local germicides are potassium perman- 
ganate, nitric acid, zinc sulphate, silver nitrate, protargol 
and argyrol. The first three are inorganic salts possess- 
ing great chemical activity. The last two, protargol 
and argyrol, are synthetic products, silver protein com- 
pounds. 

We know that the germicidal value of mercury and 
silver preparations depends especially on the number 
of the " dissociated " ions. They unite with the protein 
substances of the microorganisms to form a chemical 
compound which is only slightly soluble. As a sub- 
stance is precipitated if the product of its solubility 
is surpassed, so here there is a precipitation or coagula- 
tion of the surplus metal-protein compound contained 
in the oversaturated solution. 

If it is true that argyrol and protargol do not form 
a precipitate on the urethral mucous membrane, then 
the amount of silver protein compound formed by them 
is within the limits of its solubility, and its chemical 
activity as a germicide cannot be any greater than a 
solution of silver nitrate diluted to the point where 



96 TREATMENT OF GONORRHEA. 

precipitation with albumin no longer takes place. The 
only merit possessed by these preparations is that they 
contain a large quantity of chemically inert silver, and 
this is an advantage of only doubtful value. A phys- 
ician who is familiar with the pathology of his cases 
and who is in a position to make a correct diagnosis will 
do better not to use these and other widely advertised 
preparation of a similar nature. 

Water is the best ionizing solvent. A salt dissolved 
in equal molecular amounts in different solvents of 
equal volume will show more free ions in water than 
in any of the other solvents. The addition of alcohol, 
glycerine or ether to an aqueous solution of any of the 
silver salts will, while increasing the solibulity, decrease 
the amount of free ions and with it the chemical activity, 
the irritating qualities, and the germicidal power of the 
solution. A solution of nitrate of silver in absolute 
alcohol or ether possesses little or no germicidal power, 
because these solvents prevent its dissociation. This 
is of practical importance, because alcohol and glyc- 
erine are often used as solvents, diluted with water, 
for germicidal preparations. These solutions are infe- 
rior to aqueous solutions for local antisepsis because 
the increased solubility is obtained at the expense 
of chemical activity. 

The most potent germicides used in the treatment of 
gonorrhea are inorganic salts which dissociate to a very 
high degree in aqueous solutions. Their ions react 
separately with living matter, and the resultant ger- 
micidal action represents the product of both the cation 



GENERAL CONSIDERATIONS OF TREATMENT. 97 

and the anion. However, either one of this class of ions 
may exceed in chemical activity, so that their action is 
not an equal one. 

Not only the quantity, but also the quality of the 
germicidal action of the cation and the anion may differ. 
The cation, usually a metal, as stated above for the silver 
ion. Its action is that of a germicide, killing by coagu- 
lation or what is commonly called astringent action. 
The anion is the acid portion of the salt and its action 
depends mostly on oxidation. 

Of the salts that are used most and that can be recom- 
mended, nitrate of silver holds first place as an. astrin- 
gent germicide. Next in order comes zinc sulphate, 
and then potassium permanganate and nitric acid. 
The last two are the best oxidizing antiseptics; next 
comes zinc sulphate, and lastly there is silver nitrate. 

In the treatment of gonorrhea, as in the treatment of 
any other inflammatory process, three factors must be 
dealt with: first, the infected tissues; second, the infect- 
ing microorganism, and, third, the irritating and toxic 
metabolic products of the specific germ. The chemical 
activity which results in the formation of the metal pro- 
tein compound of the microorganism also forms a 
metal-protein compound with the tissues; and the 
chemical activity which oxidizes the microorganism also 
oxidizes the tissues. Every germicide or antiseptic is 
also an irritant to the affected tissues, and the degree of 
irritation is directly proportional to its antiseptic power. 
But, the antiseptic which acts by oxidation also de- 
stroys the metabolic products of the infecting germ, also 



98 TREATMENT OF GONORRHEA. 

relieves irritation, hence acts to a certain extent as an 
analgesic, especially in acute infections. 

The gonorrheal inflammations of the urethra which 
we are called on to treat represent all stages, from the 
very acute to the very chronic. In the acute stage the 
tissue, react vigorously to the irritation caused by the 
gonococcus and its products. A stimulating or astrin- 
gent antiseptic therefore overstimulates the tissues in 
this stage of the inflammation. The acute inflam- 
mations call for the use of oxidizing or mild germicides, 
but hydrogen peroxide should be used with great care 
only, on account of its explosive action, which irritates 
the acutely inflamed tissues of the urethra. The oxi- 
dation produced by potassium permanganate and 
nitric acid occurs without these irritant properties and, 
if used carefully, these drugs will give considerable 
relief to the mucous membrane. 

Nitric acid in i :6ooo to i : tooo aqueous solution is a 
good oxidizing antiseptic. In chronic inflammation 
the congestive hyperemia is usually of a low degree. 
The destructive stage of the inflammatory process has 
been followed by a stage of regeneration and hyper- 
plasia. The tissues react kindly to a stimulating or 
astringent germicide. 

In the instrumental treatment of chronic gonorrhea, 
which will be described fully later, a certain limited 
superficial area of chronic inflammation is changed 
by the congesting action of the dilatation into an acute 
process. It should again be irrigated with mild oxidiz- 
ing antiseptics. 



GENERAL CONSIDERATIONS OF TREATMENT. 99 

No matter how chronic the inflammatory process is, 
strong stimulating germicides like silver nitrate should 
never be used on successive days, because their ap- 
plication produces lesions which need several days for 
repair. Aqueous nitrate of silver solution of 1 : 1000 
gives the best results, if used every third or fourth 
day. The indirect therapeutic action of the drug, 
that is, the action to the deeper structure, consists in 
the production of an inflammatory hyperemia. In 
Guyon's deep injections, where we use a 1 to 2 per cent, 
solution, we depend principally on the indirect action, 
but, as we can get the same effect more accurately 
measured and better controlled and with less local lesion 
by the graduated dilatation, this method of treatment 
can hardly be rational any more. 

The physician who is thoroughly familiar with the 
action of germicides will never be misled by the pub- 
lished results of experiments conducted in an optimistic 
but not scientific spirit. He will study the pathology of 
his cases and use remedial agents, according to simple 
rational principles. He will use these agents in solu- 
tions of such strength as will do the least harm to the 
tissues, and still exert the desired effect on the germ. 
All that can be expected of any germicide is that it 
acts on the surface with which it comes in contact, 
but the irritation produced by its germicide action 
may produce a congestive hyperemia of the deeper 
tissues, and in this way help nature's effort to eliminate 
infection. The edema occurring after irrigation of the 
urethra should be regarded in that light. 



ioo TREATMENT OF GONORRHEA. 

The local treatment of gonorrhea resolves itself into 
that done by the physician and that done by the patient. 
The treatment that is done by the patient consists in 
urethral injections with a small syringe (Fig. 41). The 
size of the syringe depends on the size of the anterior 
urethra, it usually varies between 2 and 3 drachmes. If 
the syringe is too large, the injection is likely to be 
forced into the posterior urethra, and may cause com- 
plications. The patient should urinate before each 
injection, and if there is much discharge the urethra 
should be washed out with sterilized water or a boracic 




Fig. 41. 

acid solution before the injection is made. The injected 
solution should be retained in the urethra for from 
two to five minutes. This can be done easily by com- 
pressing the meatus with the fingers after the nozzle of 
the syringe has been removed. 

The irrigation of the urethra and the bladder can 
be done either with or without the use of an injector or a 
catheter. The injector is either a metal or an elastic 
instrument. Elastic instruments render good service 
in the irrigations of the anterior urethra, but when the 
posterior urethra is irrigated their elasticity is a dis- 
advantage, because the instrument will bend or curve, 
thus misdirecting the stream of the injecting solution. 
The injector should have many small openings in its 
sides or one large opening in the distal end. The 



GENERAL CONSIDERATIONS OF TREATMENT. 101 



latter is to be preferred for irri- 
gating the posterior urethra and 
the bladder. The easy and 
painless introduction of the ca- 
theter into the posterior urethra 
is made possible while the irri- 
gation is being done because the 
irrigating solution distends the 
urethra, acting as a guide and a 
lubricant. In order to irrigate 
the posterior urethra more effi- 
ciently, the instrument is intro- 
duced up to the commencement 
or the middle of the membran- 
ous urethra only. When it is 
desired to irrigate the urethra 
and bladder without a catheter, 
the nozzle of the irrigator is 
provided with an olive-shaped 
tip, which is fitted to the meatus, 
thus permitting the use of the 
urethra as a catheter. 

The pressure required may 
be supplied by the force of 
gravity, as is done when the ir- 
rigator is used, or by the hand 
of the physician, as is done when 
a syringe is used. I prefer to use 
a hand syringe (Fig. 42), which 
will hold from 100 to 150 c.c. 




Fig. 42. 



102 TREATMENT OF GONORRHEA. 

of fluid, especially in acute cases, where the irrigations 
must be done very carefully and very gently, in order to 
avoid injuring the swollen and denuded mucosa. With 
the fingers of the left hand on the urethra, and the right 
hand on the piston of the syringe, the operator can feel 
the contraction of any muscle, thus enabling him to 
make less pressure and in this way prevent straining, and 
perhaps laceration of the mucous membrane. Further- 
more, the pressure can be regulated perfectly. It is 
in our power to induce either contraction or relaxation 
of the voluntary muscles of the urethra, and to limit 
accurately the irrigation to a definite part of the urethra. 

Irrigations usually are effective in all stages of the 
inflammation, but skill and experience are required on 
the part of the physician in making them. The acuity 
of the inflammatory process is not a contraindication to 
the irrigation treatment. On the contrary, acute gonor- 
rhea is benefited very much by irrigations made with 
care and patience. It is the best treatment if the pa- 
tient can give his time to it and see the physician every 
day until the acute symptoms have subsided. 

For irrigating purposes, potassium permanganate 
may be employed in aqueous solutions in the strength 
of i : 2000 to i : 20,000, and in amounts of a pint to 
2 quarts. Zinc sulphate is used in amounts of \ pint 
to 1 quart and of a strength of 1 : 50 to 1 : 200. Nitrate 
of silver is used in a strength of 1 : 1000 to 1 :6ooo, and 
in amounts of 2§ to 8 ounces. Nitric acid is used in a 
strength of 1 : 1000 to 1 : 10,000 and in amounts of a 
pint to 2 quarts. 



GENERAL CONSIDERATIONS OF TREATMENT. 103 

INSTRUMENTAL TREATMENT. 

The instrumental treatment is of special value in 
chronic gonorrhea. This statement is not concurred 
in as much as it should be, because of the fact that med- 
ical colleges and dispensaries do not afford their stu- 
dents sufficient opportunity to study the pathology 
of this very widespread disease, one which probably 
does more harm than any other. A correct diagnosis 
cannot be made without a thorough knowledge of the 
pathology of gonorrhea, and of the correct use of sounds, 
dilators, and bougies. Of course, this knowledge is 
also absolutely necessary in order to treat these cases 
properly. The inexperienced physician will blame 
his instruments for his poor results. In the hands 
of the trained physician the instrumental treatment 
is without danger and offers the surest and speediest 
recovery. 

Every case of chronic gonorrhea, no matter how 
slight it may be in severity, is accompanied by a de- 
crease in the size of the lumen of the urethra. The 
purely cellular infiltrations, as well as the hard infil- 
trations and cicatricial tissues, diminish the elasticity 
of the tissues into which they have been deposited. 
The dilatation will first obliterate the urethral folds, 
and further dilatation is done at the expense of the 
elasticity of the urethral tissues. This elasticity is 
great in the normal tissues and only slight in diseased 
tissues. The latter are rendered hyperemic and some- 
times slightly damaged by- the dilatation. The gradu- 
ated dilatations act, first, on the superficial cellular 



104 TREATMENT OF GONORRHEA. 

infiltrations, and then on the more deeply situ- 
ated and harder infiltrations. The greatest number 
of chronic gonorrheal infiltrations can be absorbed in 
this way. In the strong infiltrations surrounding the 
glands, the interior of the gland is often influenced 
favorably long before the surrounding infiltration is 
absorbed. 

Following each dilatation there is a transitory in- 
crease in the severity of the clinical symptoms because 
the irritation caused by the instrument has stimu- 
lated nature to make an increased effort at repair. 
The increased pathologic secretion comes from the 
infiltrated patches as well as from the glands. The 
weaker dilatations attack and dissolve the infiltrations 
rich in granulation tissue, while the stronger or more 
forcible dilatations influence also the infiltrations con- 
taining organized connective tissue. The truth of 
this statement can be verified by a urethroscopic ex- 
amination. 

The appearance of the diseased surface changes 
after each dilatation. Connective tissue freed from 
granulation tissue is gradually coming to the surface. 
The action of dilatation is the same in infiltration of 
every degree. The reaction to the dilatation may 
differ in quantity but not in quality. The cellular in- 
filtrations decrease gradually with each dilatation, 
but the remaining connective tissue is not freed from 
cellular elements, and is, therefore, still capable of re- 
acting and of being absorbed. 

A few days after a successful dilatation the urine 



GENERAL CONSIDERATIONS OF TREATMENT. 105 

is found to contain secretion and threads in abundance. 
The patches of connective tissue, wrongly called scars, 
that appear during the course of the dilatation, are 
seen for from ten to twenty days only. They then 
gradually disappear. Oberlaender and Kollmann are 
convinced that connective tissue reacts and is absorbed 
for many years, even decades. 

The action of graduated dilatation is both a mechan- 
ical and a dynamic one. It is massage treatment that 
produces changes in the vital properties of the pathologic 
tissues. Finally, a stage is reached in which the dila- 
tations fail to cause any more reaction and absorption. 
Except in isolated instances this is the stage of cure. 

The inflammatory process is most persistent around 
the glands. After the stage of reaction is passed, hard 
nodules of the size of a pea or smaller may be seen in the 
vicinity of the inflamed glands. Lohnstein has called 
these nodules fibrous depositions. They are the remains 
of hard infiltrations, and usually contain glands, that 
are surrounded by organized connective tissue. Some- 
times the gland itself has undergone connective tissue 
changes. In large urethras the dilatations may cause 
the absorption of all the infiltrations of the mucosa, 
but not of the infiltrations in the erectile tissue. These 
latter escape the effects of the treatment by getting out 
of the way of traction. 

The use of dilatations in the treatment of gonorrhea 
is not new. Dilatations have been practiced empirically 
and in rather a crude way for a long time. The bene- 
ficial effect obtained from the introduction of a common 



io6 TREATMENT OF GONORRHEA. 

sound into the urethra is due to its dilating and congest- 
ing action on the most prominent infiltrations. The 
graduated dilatations are an improvement on the old 
sound method. They are based on the special pathology 
of the condition, are controlled by the eye of the opera- 
tor, and are executed with adequate instruments. Neel- 
son and Oberlaender have given us the special pathology 
of the gonorrheal affections, while Nitze and Valentine 
have supplied us with a urethroscopic lamp which is in- 
valuable in diagnosis and indispensable in the rational 
treatment of gonorrhea. Kollmann, with the aid of 
his instrument-maker, Heynemann, of Leipzig, has con- 
structed instruments which permit of the treatment of 
any part of the affected urethra. 



CHAPTER IX. 

TREATMENT OF THE VARIOUS STAGES OF 
GONORRHEA. 

ACUTE GONORRHEA. 

Acute gonorrhea is a contraindication to the use of 
instruments either for diagnostic purposes or for treat- 
ment. For a diagnosis we must depend mainly on the 
microscopic examination of the secretion vide page n 
and on the various diagnostic glass tests vide page 22. 
The treatment is limited to the use of medicines in- 
ternally, injections, and irrigations. 

There is no one way of treating acute gonorrhea 
which can be termed the best method of treatment, 
because the success of any method depends in a large 
degree on the skill and experience of the physician and 
the willingness of the patient to follow instructions. 
The best results are obtained from daily irrigation with 
a warm potassium permanganate or nitric acid solution 
in increasing strength and given with a hand syringe 
without the use of an injector. 

The first irrigation should consist of one or two 
quarts of a 1-10,000 to 1-20,000 aqueous solution at 
a temperature of 40 to 45 C. Three or four syringe- 
fuls are used to wash out the anterior urethra, and the 
remainder is allowed to flow into the bladder, which 
should be emptied after each injection. Much patience 

107 



io8 



TREATMENT OF GONORRHEA. 



and skill are necessary when this first treatment is given, 
especially in very acute cases. Fig. 43 shows the 
manner in which the syringe is used, with the patient 
in the standing position. As little force as possible 
should be used, because the acutely inflamed mucous 
membrane is less elastic than the remainder of the tis- 
sues, and is injured if the irrigating fluid causes too 
much tension. The ballooning of the urethra must be 




Fig. 43. 



done gradually or abandoned entirely during the first 
few irrigations. As the acute symptoms subside, the 
strength of the irrigating solution is increased gradually 
to 1-2,000. Before each treatment the patient is ques- 
tioned as to how the previous irrigation acted; how 
long afterward he noticed increased burning of the 
urethra, and how often he had to urinate. According 
to the reaction produced by the previous irrigation, 



VARIOUS STAGES OF GONORRHEA. 



109 



the strength and the amount of the solu- 
tion used is increased or decreased from 
day to day. Each patient must have 
his case studied carefully and treated in- 
dividually. Until the acute symptoms 
have subsided, it may be advisable to 
irrigate twice a day, irrigating the urethra 
and bladder in one sitting, and the an- 
terior urethra alone in the other. 

In from four to ten days, when the 
discharge usually is stopped, the patient 
is directed to take two or three injections 
at home, visiting the doctor only once a 
day for irrigation. Internal medication 
given in connection with the irrigation 
treatment does not seem to have a bene- 
ficial effect. The urethra is kept irri- 
tated, and it does not permit increasing 
the strength of the irrigating fluid as 
rapidly as can be done when no internal 
medication is given. Less experience is 
required when the irrigations are given 
with Valentine's (Fig. 44) or an improved 
irrigator, than when the syringe is used. 
Therefore, the former are to be recom- 
mended to physicians who treat these 
cases only occasionally. If the irrigation 
is done by means of an injector or a ca- 
theter, the urethra is not ballooned, and 
the drug remains in contact with the 



mi 



Fig. 44. 



no TREATMENT OF GONORRHEA. 

mucous membrane only when flowing out. The irri- 
gating fluid can be used in greater strength when the 
injector is used. 

Some clinicians limit the irrigation to the anterior 
urethra unless there are distinct symptoms of a pos- 
terior urethritis. Others begin with posterior irriga- 
tions on the supposition that a posterior infection exists. 
No fears need be entertained that an infection will be 
produced by continuity; on the contrary, irrigations of 
the whole urethra given properly will prevent just such 
an occurrence. I have not had a single case of epididy- 
mitis in the past three years in any acute case that I 
was permitted to watch closely, pushing the irrigation 
treatment. 

In cases where the discharge is profuse and purulent, 
and when the patient cannot take daily irrigations, it 
is advisable to give internal treatment (ten minims of 
oil of sandalwood, three times a day) for two or three 
weeks, provided that the inflammatory conditions are 
subsiding under its influence. In some cases internal 
medication is absolutely without benefit, and it should 
then be discontinued entirely. The therapeutic action 
of the balsamics is enhanced if the liquid diet is cut 
down and the urine concentrated. At the end of the 
first or at the beginning of the second week the local 
application of a germicide is added to the internal 
treatment. 

The patient is directed to make injections three to 
four times daily and to retain the fluid in the urethra 
for from two to five minutes. A 1-5,000 to 1-500 solu- 



VARIOUS STAGES OF GONORRHEA. in 

tion of potassium permanganate or nitric acid the 
strength being increased gradually, are the ideal in- 
jections for this stage of the inflammation. 

A week or two after the injections were begun, the 
acute symptoms ought to have subsided considerably. 
The urethral mucous membrane is then not suffering 
so much from the irritation produced by the inflam- 
matory products. The permanaganate of potash may 
be replaced gradually by a more stimulating (irritating) 
germicide. An aqueous zinc sulphate solution in the 
strength of i : 200 to 1 : 50, is used once a day, in the 
evening, at first, the frequency of its use being increased 
until no more potassium permanganate is used. 

The patient afflicted with acute gonorrhea should 
rest in bed as much as possible, and, when up, wear 
a well-fitting suspensory, padded with cotton. The 
cotton should be changed every day, and should be 
dusted with starch, in order to prevent the forming 
of eczematous conditions, due to sweating. 

All fermented drinks are injurious. Even an excess 
of water should be avoided, since micturition disturbs 
the rest of the urethra. 

The patient's food should be simple, bland and not 
flavored. The diet should consist as much as possible 
of vegetables. 

Milk, with little or no coffee, in the morning. 

Soup, vegetables and farinaceous food, with but 
little meat at noon, and milk, farinaceous food and fruit 
for supper. 

The last meal should be taken at least two hours before 



ii2 TREATMENT OF GONORRHEA. 

going to bed, in order to prevent erection and emissions. 
The patient should sleep in a cool room, and not cover 
himself up too warmly. He should wear good foot- 
wear, especially in winter and in wet weather, because 
wet and also cold feet favor the occurrence of strangury 
and favor the appearance of cystitis. 

In order to protect the clothing, the patient should 
lay cotton or gauze, soaked with 2 per cent, lead acetate 
solution, between gland and foreskin. 

If there is much swelling of the penis and edema of 
the prepuce, the treatment may have to be limited at 
first to the applications of hot compresses (flaxseed), 
and to regulation of the diet. Frequent and painful 
urination can be reduced by hot hip baths or hot ap- 
plications to the penis; in severe cases the following 
prescription is of value: 

1$ Ex. hyoscyamii, ) __ 

Ex. cannabis Indica, j ° ' 

Sacchari, q. s. ad., 5j. 

M. et ft. chart. No. X. Three to four powders a day. 

For terminal bleeding, which sometimes occurs during 
the acute stage, the following prescription is of value: 

R Ferri chloridi, gr. xxiv. 

Syr. rubi Idaei, 3 v. 

Aq., q. s., ad., § v. M. 

5j six to eight times a day. 

Injections and balsamics should be stopped for the 
time-being, if either frequent and painful urination or 
terminal bleeding occurs during treatment. 



VARIOUS STAGES OF GONORRHEA. 113 

In the following will be given some prescriptions of 
the most efficient injections: 

1$ Ac. nitrici, gr. iii to xv. 

Aq., q. s., ad., gviii. 

Inject three to four times a day. 

1$ Ichthyol, grs. xx to 5 jss. 

Aq., q. s., ad., giv. 

Inject three times a day. 

1$ Zinc sulphs. carbol., gr. viii to xvi. 

Aq., q. s., ad., Sviii. 

Use as an injection. 

1$ Alum crudi, 5j to 5ij. 

Aq. font Sviii. 

Use as directed. 

fy Zinc acet, gr. x to xvi. 

Aq., q. s., ad oiv 

1$ Zinci sulphatis, 

Plumbi acetatis, aa gr. 7 to 40. 

Tinct. catechu, 3 1 to 2. 

Aq., dest. q.s., ad., . . 5 4. 

(Kollmann.) 

If the secretion has not ceased after a month or two 
from the beginning of the affection, the case is usually 
in the subacute stage (soft infiltrations) and instru- 
mental treatment is indicated. 

CHRONIC GONORRHEA. 

Chronic gonorrhea is the field for instrumental diag- 
nosis and treatment. The instrumental treatment is 
indicated by the pathologic changes in the mucous 
membrane as seen in the urethroscopic examination. 
Although the pathologic lesions are dependent on the 



ii 4 TREATMENT OF GONORRHEA. 

presence of the gonococci, they are not always found 
in the secretions. The physician must be careful, especi- 
ally at the beginning of treatment, when there is still 
some uncertainty as to the diagnosis, not to crowd in- 
strumental treatment. Neurasthenics and those whose 
resistance has been reduced by excesses do not stand 
instrumental treatment well. The reactions are usually 
stormy and affect the general health of the patient very 
much. 

a. The soft infiltrations are manifested clinically 
as subacute or obstinate acute cases. The very severe 
acute cases, which last from three to four months, and 
are often accompanied by complications, are not among 
the soft infiltrations. In the case of the soft infiltrations 
there either never was much secretion and apparent 
inflammation, or there was at first well-marked inflam- 
mation without much secretion, which was followed 
by a very lingering stage. Another characteristic 
feature of these cases is the fact that the lapse of time 
since the original infection is a very short one, usually 
only a few months. The clinical symptoms are not 
always an indication of the pathologic changes in the 
mucous membrane. It is impossible always to give a 
reason for this discrepancy between the clinical symp- 
toms and the pathologic findings. We are, therefore, 
not justified in making a diagnosis of the character of 
the urethral affection before a urethroscopic examina- 
tion is made. 

A patient who can bear the irrigations well will also 
bear the urethroscopic examination. We should also 



VARIOUS STAGES OF GONORRHEA. 115 

make it a rule always to sound or catheterize a patient 
as soon as it is possible to do so in order to determine the 
existence of coarser changes and to anticipate trouble. 

Soft infiltrations of the anterior urethra are usually 
accompanied only by soft infiltrations of the posterior 
urethra unless there exist the remains of an old infection. 
The passage of sounds or of a catheter is somewhat 
painful, and causes some bleeding. Narrowing of the 
urethra is not a prominent part of this form of infiltra- 
tion. 

Having made the correct diagnosis, it is advisable to 
wait a few days before beginning the treatment, because 
the primary examination usually is followed by some 
reaction, such as burning on urinating, and a slight 
increase in the discharge. If this reaction does not 
subside spontaneously within a day or two, warm irri- 
gations with potassium permanganate or boric acid, 
followed by silver nitrate, are indicated. We may 
dilate without waiting for the passing off of the reaction. 
If the caliber of the meatus permits of the introduction 
of a four- branch dilator, it may be used at once. Unless 
there are patchy infiltrations at the orifice or in the glans 
penis, a previous preparation of the urethra with straight 
sounds is not necessary in this class of cases. The dila- 
tor must be employed here as well as elsewhere with 
care. Lacerations of the orifice deserve special atten- 
tion and may demand the use of short dilators. 

The irrigating dilators are also used with great bene- 
fit in the soft infiltrations, especially if the excretory 
ducts of the glands are swollen and stopped up with 



n6 TREATMENT OF GONORRHEA. 

stringy secretion. In order to avoid overirritation, 
the first dilatation should be done with the size of the 
instrument not more than one or two numbers larger 
than that of the urethroscopic tube used during the 
examination. The secret of the successful treatment 
of chronic gonorrhea lies in the adequate gradation and 
the timely repetition of the dilatation. It is not possible 
to do this successfully without having had experience, 
but strict observation of the rules laid down below will 
protect the beginner from gross mistakes and failures. 

There should not be much bleeding either after ure- 
throscopy or dilatation, especially not at the commence- 
ment of the treatment. The change that takes place 
in the secretion after dilatation differs in each case. 
A case which may have shown only filaments before 
dilatation was begun may be accompanied by a very 
severe discharge afterward, while in another case the 
reverse may be true or there may be complete cessation 
of the secretion. It is not always possible to give a 
satisfactory explanation for these varying conditions. 
Much depends on the nature of the disease and on the 
individual peculiarities of the urethral mucous mem- 
brane. In the case of the soft infiltrations the pain on 
urination and erection disappears after each dilatation 
within from twelve to twenty-four hours. If the pain 
lasts longer than this, then we have either dilated too 
much, or a mistake was made in diagnosis. 

The treatment to be given between the dilatations 
depends on the reaction in general and on the increase 
in secretion. If it is impossible for the patient to receive 



VARIOUS STAGES OF GONORRHEA. 117 

treatment daily, he must be instructed to make from 
three to four injections daily with potassium perman- 
ganate or with zinc sulphate. However, in order to 
secure speedy and complete healing, it is desirable to 
make daily irrigations with potassium permanganate, 
or every third day with nitrate of silver. The nitrate 
of silver irrigations are to be preferred in cases where 
the mucous membrane reacts kindly to this agent. 
Irrigation of the posterior urethra should always be 
done by the physician. 

The following course of treatment is advisable if 
the patient can give the necessary time to it and if the 
physician is desirous of using all means possible to pro- 
duce a speedy cure. On the day following the first 
dilatation, an irrigation with potassium permanganate 
in the strength of 1-6,000 to 1-3,000 is given. 

1$ Potassii permanganati, gr. 2\ to 5. 

Aquae, q. s., ad., quart 1. 

On the second day a 3 to 4 per cent, boric acid wash 
followed by a nitrate of silver (1-4,000 to 1-1,000) 
irrigation is given, 

1$ Argent, nitrat., gr. j to iv. 

Aq. destill., q. s., ad., § viii. 

and on the third day and perhaps also on the fourth and 
fifth days, potassium permanganate is to be employed 
again. Depending on the severity of the reaction pro- 
duced by the first nitrate of silver irrigation, two, three, 
or more days are allowed to elapse before another ap- 
plication is given. The discharge ought to diminish 



n8 TREATMENT OF GONORRHEA. 

considerably, the urine clear up, and the filaments 
become less numerous in from twelve to twenty-four 
hours after the use of the nitrate of silver. If these 
changes do not occur, it is an indication that the case 
is not ready for such irrigation. Potassium perman- 
ganate irrigations must then be continued. If the treat- 
ment has lasted for some time, nitrate of silver should 
be tried again. 

Soft infiltrations that are discharging slightly and 
that do not react promptly to the dilatations and on 
which silver salts do not exert a favorable effect, are 
influenced satisfactorily by zinc sulphate or zinc tannin 
used every other day. It does not matter whether only 
the anterior urethra or the entire urethra is to be irri- 
gated. Suitable injections should be taken at home with 
a small syringe once or twice a day as long as there 
exists a considerable discharge. Daily irrigations, 
either with or without a catheter, should not be used for 
weeks unless it is impossible to control the discharge. 
Too much treatment will prolong the inflammation, 
while not enough fails to control the disease. 

In soft infiltrations the reaction that follows the 
dilatations is somewhat proscribed, and even though 
the secretion may be increased considerably, the con- 
dition is not of long duration. Within four to eight 
days the condition will return to what it was before 
any dilatation was done. The second and subsequent 
dilatations should be repeated at intervals of ten days. 
The increase in dilatation should not be more than 
one to two numbers at each treatment, unless no reac- 



VARIOUS STAGES OF GONORRHEA. 119 

tion followed the last dilatation given, and the urethro- 
scope fails to show any marked lesions. In these 
exceptional instances the increase may be from three to 
five numbers. The increase in dilatation is always 
governed by the apparent increase of the irritation 
and secretion following the last instrumental treatment. 
If more than one week is required to overcome the 
reaction, the increase at the next dilatation should not 
exceed one number, and in some instances it may 
be advisable not to increase the number at all. If, on 
the contrary, the dilatation produces no reaction, an 
increase of two numbers will not cause any trouble. 

If the catarrhal condition becomes lessened in the 
intervals between dilatation, these may be made longer, 
until finally, when the secretion has ceased and the fila- 
ments have disappeared, dilatation treatment is dis- 
continued. It is advisable, however, to make one or two 
additional injections of nitrate of silver solution in the 
strength of 1-1000 to 1-500. 

Relapses also occur in the case of the soft infiltrations, 
but they are not very common. If, on urethroscopic 
inspection, the five-glass test and the milking of the 
prostate give negative results, the treatment may be 
stopped for several weeks when another examination is 
made. In these infiltrations the mucous membrane 
reverts practically to its normal condition, although 
some of the crypts may show signs of irritation for 
some time afterward. 

The degree to which the dilatation may be carried 
is governed entirely by the susceptibility of the patient 



120 TREATMENT OF GONORRHEA. 

and the reaction that is produced. Neither the absence 
of gonococci nor the histologic condition of the fila- 
ments justifies the physician in pronouncing the patient 
cured. It is of little importance whether the filaments 
contain only epithelium, or epithelium and leucocytes. 
Filaments consisting of mucin and leucocytes are irrel- 
evant. The patient should be urged to hold the urine 
as long as possible before visiting the physician, because 
the urine is a guide to the healing. A rich purulent 
secretion produces a turbid urine with filaments ; where- 
as a slightly purulent, muco-purulent and purely mucous 
secretion contains only filaments. 

It is only infrequently that the prostate is affected 
in soft infiltrations. 

As to the duration of the treatment, it may be said 
that mild muco-purulent catarrhal conditions heal after 
three or four dilatations and from six to eight irrigations 
with nitrate of silver, or in from five to six weeks. 
The more severe the catarrh, the more time is required 
to effect a cure. If healing does not take place in the 
time expected, another examination should be made, 
when it will probably be found that the case is not of the 
uncomplicated variety. 

The affections of the posterior urethra are seldom 
well-marked in the soft infiltrations of the anterior ure- 
thra. This is easy to understand when we take into 
consideration the histology of the anterior urethra. 
It is more conducive to the lodgment of infective agents 
than is the posterior urethra. The conditions are dif- 
ferent if an infection of the prostate and seminal vesicles 



VARIOUS STAGES OF GONORRHEA. 121 

has taken place. An infection of the prostate cannot be 
governed with any degree of certainty, but experience 
teaches that the obstinate cases of prostatitis are sel- 
dom accompanied by soft infiltrations only of the ante- 
rior urethra. 

Soft infiltrations of the posterior urethra are of short 
duration and cause the patient almost no suffering. 
There may be present a feeling of tension and of tickling 
in the perineum, and a slight increase in the frequency 
of urination. Even severe purulent inflammations of 
the posterior urethra do not always manifest themselves 
by marked symptoms. It is only after the inflamma- 
tion reaches a certain depth, especially when it attacks 
the muscular fibres, that there is severe tenesmus 
on urination. 

The treatment of this condition varies as does that 
of the anterior urethra, depending on the stage of inflam- 
mation. We may give daily irrigations with potassium 
permanganate or two to three times weekly with zinc 
sulphate (J per cent, to 1 per cent, solution), and per- 
haps once or twice weekly irrigation with a \ to 1 pro- 
mille solution of nitrate of silver. 

Dilatation of the posterior urethra seldom is neces- 
sary in this class of cases. If the inflammation fails 
to yield to irrigations, we are dealing with a case of 
hard infiltrations. From the posterior urethra the in- 
flammatory process usually extends to the intra vesicular 
portion of the urethra, to the trigonum vesicae. The 
cystoscope discloses a urethro-cystitis which is charac- 
terized by a deep red color and great brilliancy of the 



i22 TREATMENT OF GONORRHEA. 

epithelial covering of the trigone. The internal ad- 
ministration of balsamics may be advisable in this class 
of cases as an aid to the local treatment of the urethra 
and bladder. 

b. The hard infiltrations are of the first, second 
and third degrees. The treatment of the first two 
varieties is practically identical and will be described as 
such. From fifty to seventy per cent, of all cases of 
chronic gonorrhea come under these two classes. Cal- 
culating from the time infection takes place, it takes 
about three or four months for the case to develop; 
but if left alone or if treated irrationally, the case may 
last ten, twenty, or more years without losing any of 
its infecting power. From this case there may spring 
a severe acute gonorrhea on the mucous membrane 
of any other person. The old belief that a chronic 
gonorrhea of long duration produces only a mild in- 
fection is a wrong one. 

The culture medium plays a very important role in 
the production of an infection. A susceptible mucous 
membrane may be attacked by a virus of low vitality 
and made the seat of a very virulent infection. Any 
secretion, no matter how slight in quantity, from tissues 
known to be infected by the gonococcus should not 
only be looked on with suspicion, but must be pro- 
nounced to be infectious. In this class of cases no 
conclusion can be drawn from the appearance of the 
gonorrheal discharge as to the duration or location of 
the infection nor as to whether the infiltrations are deep 
or superficial. The discharge increases and becomes 



VARIOUS STAGES OF GONORRHEA. 123 

purulent in reinfections, but the same symptoms may 
be apparent in relapses. There are many reasons 
why the discharge at one time appears in the form of a 
drop and at other times in the form of filaments. 1. 
The most important factor in determining the charac- 
ter of the discharge is the location of the infection. 
An infection in the fossa navicularis will manifest it- 
self at the meatus much sooner than an infection of the 
bulb. 2. The structure of the penis is also a deter- 
mining factor because well -developed longitudinal 
folds will hold more of the discharge than slightly 
developed and partly obliterated folds. 3. A natur- 
ally dry mucous membrane will keep more pus back 
than a naturally moist one. 4. An active patient 
is more likely to have a discharge than a patient who 
has sedentary habits. The meatus will often be dry 
in the morning on arising and pus will make its ap- 
pearance after the patient has been walking about 
for a while. 5. The consistency of the pus deter- 
mines whether or not it will make its appearance at 
the meatus. For these reasons the appearance of a 
discharge at the meatus is an important but by no means 
a diagnostic symptom. Posterior urethritis, pros- 
tatitis, and sometimes even cystitis may complicate a 
chronic gonorrheal inflammation without being man- 
ifested by subjective symptoms. However, it is not 
always necessary to do a posterior urethroscopy at 
the beginning of the treatment. The anterior urethra 
is examined with the urethroscope before commenc- 
ing the treatment, and, if possible, before each dilata- 



i2 4 TREATMENT OF GONORRHEA. 

tion. A record should be kept of the results of each 
urethroscopic examination. The following outline by 
Kollmann and Oberlaender (Fig. 45) will aid in the 
taking of the records. 

A microscopic examination should be made of the 
urethral and prostatic secretions. If no secretion can 
be obtained, the filament in the urine should be ex- 
amined. The determination of the source of the secre- 
tion (pus or filaments) is not always an easy matter, 
and it may be necessary to make repeated examina- 
tions. A definite diagnosis should be withheld until 
every aid in diagnosis has been employed. 

The treatment of the disease is relatively simple, 
and gross therapeutic errors are, as a rule, only made 
when the disease has not been located correctly. Be- 
fore commencing the treatment, the physician must in- 
form himself as to the stage of the inflammation at that 
time, and acute exacerbations of chronic conditions 
must be treated by irrigations and perhaps by internal 
medication before commencing the dilatations for the 
purpose of treating the disease proper. It is always 
best to wait a few days longer before instituting instru- 
mental treatment, because, otherwise, one may be sur- 
prised disagreeably by the reaction following the first 
dilatation. This is very important for the progress of 
healing, and in order to be on the safe side it may be 
advisable to start dilating with metal sounds first, 
using the dilators later on, when more familiar with 
the case. The reaction following the first dilatation 
is waited for and watched carefully, and then made to 



VARIOUS STAGES OF GONORRHEA. 125 

ObereRaUU ITniereKalfU 




Fig. 45. 



126 TREATMENT OF GONORRHEA. 

disappear by irrigations of potassium permanganate 
and nitrate of silver. Before another dilatation is done, 
this reaction must have run its course and the secre- 
tion must not be any greater in amount than it was be- 
fore the first dilatation. 

Any slight pain on urination which was caused by 
the instrumental interference must have disappeared 
before another dilatation was done. Sometimes four- 
teen days or more will elapse before conditions are such 
that another dilatation may be attempted. In the later 
stages of the condition and in cases accompanied by 
rich epithelial changes the effect of the dilatation mani- 
fests itself by the appearance of large quantities of 
epithelial scales in the urine. These latter soon dis- 
appear after proper irrigation treatment. If there 
was much hemorrhage following the last dilatation, 
it is best to lengthen the interval between dilatations 
two days more than would otherwise be done. 

In the course of the graduated dilatations there is 
reached eventually a point where the same number 
must be used for several dilatations in order to keep 
the reaction within the prescribed limit. An increase 
is not permitted until the reaction has become very 
slight. There can be no deviation from the rules 
laid down with reference to the gradual increase in 
dilatation unless the case has been studied during 
previous treatment. If it has shown itself to be unreli- 
able in the reactions produced it would be absolutely 
necessary to adhere closely to the instructions given 
during the course of the treatment. To deviate from 



VARIOUS STAGES OF GONORRHEA. 127 

this course and to start at once with a strong dilatation 
will tear the infiltrated patches and result in an abuse 
to the tissues that cannot be remedied easily. 

At the commencement of the treatment we are usu- 
ally obliged to use straight sounds of small size, or 
small two-branched dilators, but as healing progresses 
we can gradually resort to the use of larger instruments, 
such as the three and four-branched dilators. As 
long as there is a discharge at the meatus or filaments 
appear in the urine that comes from the anterior ure- 
thra, we must not jump several numbers in the dilata- 
tion from one treatment to the other. 

Besides regulating the dilatations and controlling 
the discharge, we must keep ourselves posted as to the 
status of the urethral affection by frequent urethroscopic 
examinations. The importance of this procedure 
will be apparent when we consider that the dilators 
must be changed during the course of the treatment, 
according to the disappearance of the infiltrations. If 
the treatment must be long-continued, the urethra should 
not be entered with instruments, especially not metal 
instruments, more than two or three days in succession. 
This is of importance in cases in which there is much 
discharge, and in those inclined to exacerbation. In this 
class of cases the dilatations can usually be repeated 
every six to ten days, but how long this can be done it 
is impossible to say before-hand, especially in strongly 
developed cases. Factors which will influence the 
length of time of the treatment are peculiarities of the 
mucous membrane or of the organism in general, and 



128 TREATMENT OF GONORRHEA. 

the presence or absence of diseases of the adnexa. Do 
not change the method of treatment if the process of 
healing is not satisfactory, but correct the manner of 
applying the treatment, so as to suit the case. This 
holds true for the use of antiseptics as well as for the 
use of instruments. Much experience is required to 
do the right thing at the right time. 

In the mixed infections {staphylococcus pyogenes 
aureus) or in infections of the urine, the result of treat- 
ment sometimes is very discouraging. Patience and 
careful work are essential to good progress. At last we 
may be able to dilate without producing chills and fever 
or other sequelae, such as pain in the joints and muscles, 
or a general feeling of disease. We way think that the 
stage of fever reaction has passed, when suddenly, after 
a somewhat stronger dilatation, a systemic reaction 
again makes its appearance. The treatment cannot be 
hurried; doing so will interfere with good results. 

No case in this class can heal without relapses. If 
we meet with such an anomalous case, it is probable 
that the relapses have been present during a previous 
treatment. The clinical symptoms of a relapse may 
be weaker or stronger than the original infection, but 
in the latter case it is probably a reinfection. This 
suspicion is confirmed if, on urethroscopic examination, 
we find that the inflammatory conditions have spread 
over the original area again, or are even reaching beyond 
the original limits, and if a great number of gonococci 
are found in the discharge. We can only call it a re- 
lapse if weeks or months of comparative well-being 



VARIOUS STAGES OF GONORRHEA. 129 

and continued improvement have intervened, and if 
the clinical improvements have been corroborated by 
the urethroscopic findings. 

A typical relapse is preceded by urethroscopic changes 
and by the appearance of filaments in the urine in 
gradually increasing amounts. The duration of re- 
lapse is uncertain, but it can be influenced more easily 
by the treatment than the original infection. Relapses 
occur most often in the upper half of the bulb. In 
this class of cases we usually get from two to three re- 
lapses before the patient is cured definitely. 

The irrigating dilators make it possible to influence 
simultaneously the deeper structures by dilatation 
and the superficial ones by irrigation. In soft infiltra- 
tions which do not extend deeply into the tissues, the 
beneficial influence of these measures is relatively lim- 
ited. It consists principally in spreading out the folds 
and enabling us to make a perfect irrigation of the 
entire surface of the mucous membrane. 

In the hard infiltrations of the first and second de- 
grees, we must deal with superficial and deep affections 
of the mucosa, a promising field for instrumental treat- 
ment. The irrigating dilators are especially to be rec- 
ommended in cases where the common dilator does 
not give satisfactory results. The patients bear this 
treatment better than when the common dilators are 
used, and therefore they are especially useful in sus- 
ceptible cases. The irrigating fluid should be used as 
warm as possible. The rules given for the use of the 
simple dilator hold good here too. 



i 3 o TREATMENT OF GONORRHEA. 

The rules given under soft infiltrations as to the 
discharge of the patient hold good here, too, and it may 
be said further that the more work and time is de- 
manded by the healing process, the longer the patient 
should be kept under observation before he is discharged 
finally. The filaments in the urine should not contain 
leucocytes in any considerable amount. 

SPECIAL THERAPEUTICS OF THE ANTERIOR 

URETHRA. 

In the case of the hard infiltrations of the anterior 
urethra, Kollmann advises to begin the dilatation treat- 
ment with straight metal sounds. He lays down the 
following rules: Begin with No. 15 Charriere and 
increase in the same sitting, if narrow parts or pains 
do not prevent it, to No. 20. If the reaction is slight, 
the procedure may be repeated four or five times, 
within fourteen days, increasing one to two numbers 
at the beginning, and one to two numbers at the end 
of each treatment. There need be no fear on the 
score of introducing several instruments in one sitting, 
because they do not pass beyond the bulb and any 
irritation of the prostate gland or the ejaculatory ducts 
is excluded. 

The size to which the sounds may be increased de- 
pends, first, on the caliber of the meatus. In a large 
number of cases No. 28 can be reached gradually with- 
out meatotomy. After having reached this number, it is 
advisable to discard the sounds and use the dilators. 

The first dilatation should be made very carefully, 



VARIOUS STAGES OF GONORRHEA' 131 

increasing only one or two numbers over the size of the 
urethroscopic tube which passes the meatus with ease 
and without causing any reaction. If the tube produces 
a reaction, the dilatation should not be carried beyond 
the number of the tube. 

Straight instruments with a large surface dilatation 
should be used as long as there exists a uniform dis- 
tribution of the infiltration. In small urethrae and 
when strong infiltrations are present, it may be neces- 
sary to use two-branch dilators first, and not until the 
healing has progressed somewhat should the four- 
branch dilators be used. The length of the penis must 
also be considered in the choice of the dilator. 

The irrigating dilatation is best done with a three 
or four-branch Kollmann instrument. After a few 
dilatations with the straight dilator, the infiltrations 
may be dissolved into patches, or those in the shaft 
may be absorbed, so that only the infiltrations of the 
bulb remain. • The latter are not acted on by the straight 
dilator because of the large size of the bulb. There- 
fore, the urethroscopic examination of the bulbous 
region reveals a dry epithelial surface with the central 
field of the funnel covered with pus. 

The bulb is treated with a curved dilator, the distal 
part of which has entered the membranous urethra. 
With the patient in the recumbent position, the dilator 
is in place when the shaft is at an angle of between 90 
and 45 degrees. In order to determine its location 
more accurately, the distal end of the instrument may 
be palpated through the rectum. It does not matter 



132 TREATMENT OF GONORRHEA. 

whether the dilator has a Dittel or a Guyon curve, but 
it is of importance that its dilating portion conforms 
more or less to the shape of the bulb. In the case of 
patients who have a long anterior urethra, we may use 
dilators which dilate in the shaft as well as with the 
curve. A short anterior urethra may be dilated with 
an instrument that dilates only with the curve. 

Mistakes are often made in the dilatation of the 
anterior urethra which retard the healing of the case. 
These consist either in too much or too little dilatation, 
in too rapid dilatation, or in choosing the wrong instru- 
ment. The mistake made most often is to combine 
too great dilatation with too short intervals between 
each dilatation. This does not permit of the gradual 
retrogression of the affected tissues throughout their 
entire extent. The mucous membrane heals only at 
the points of greatest dilatation. It does not matter 
much whether the dilatations result in the production 
of a tear in the surface of the mucous membrane, or 
trauma or contusion of the submucosa; the process 
of retrogression in either case in incomplete or faulty. 
These results are caused by the use of a faulty technic, 
even when the instrument is a good one. These cases 
are recognized urethroscopically by the existence of 
numerous loose hypertrophied folds and glandular and 
periglandular infiltrations. In such cases dilatation 
should not be made for a month or two, or even more, 
depending on the severity of the previous treatment. 
In the meantime mild irrigations or injections may be 
employed, and the adnexa treated if they are affected. 



VARIOUS STAGES OF GONORRHEA. 133 

Before resuming the dilatations, a careful urethro- 
scopic examination should be made for the purpose of 
determining the location of the diseased parts. This 
can be done better now than immediately after the 
cessation of the instrumental treatment, because the 
affected parts stand out more prominently. Choose a 
suitable dilator, and exercise great care in its use, so as 
not to do further harm. Dilate slowly and, if neces- 
ary, use the same number at several dilatations. 

The healing may be retarded further because the 
inflammation has localized itself in isolated crypts 
and glands and their immediate surroundings. The 
infiltrations are located deeply in the tissues, and there- 
fore are affected only slightly or not at all by the dilata- 
tions. 

In these cases the urethroscopic examination shows 
pus discharging from the excretory ducts of the glands 
and their surroundings. The central field of the mem- 
branous funnel is covered with pus even after a long- 
continued course of instrumental treatment. 

In gonorrheal infiltrations which have failed to yield 
to the common dilator, Oberlaender has of late been 
using the irrigating dilator twice a week, with most 
satisfactory results. He uses equal parts of zinc sul- 
phate and alum in the strength of 1-200 to 1-50. We 
must try to obtain high dilatations. 

If this treatment also fails to effect a cure, the glands 

must be destroyed by electrolysis. For this purpose 

Kollmann's bayonet-shaped electrolytic sounds (Fig. 

9) are the best. In the glands with gaping excretory 
10 



i 3 4 TREATMENT OF GONORRHEA. 

ducts use the blunt electrolytic sound, and in glands 
with narrow excretory ducts pointed electrolytic sounds 
are used. The sound is connected with the negative 
pole of the battery, while the positive electrode is ap- 
plied over the symphysis. The electric current is 
turned on slowly to about 1.5 to 2.5 milliamperes. 
It is not advisable to use a current stronger than this. 
Gas bubbles are generated and can be seen as soon as 
electrolysis is well under way. The first sitting should 
not last more than one or two minutes. Kollmann 
does not, as a rule, extend the treatment over one minute 
either at the first or at subsequent visits. 

After a successful electrolysis the parts surrounding 
the gland are distinctly congested, and they remain so 
for from four to six days, when the absorption of the 
destroyed tissues begins. It is completed in from four 
to six or eight weeks. 

The long time required to produce healing is a great 
disadvantage of this method of treatment. If the glands 
are not too close together, more than one gland may be 
destroyed in one sitting. The swelling that follows 
each treatment makes it impossible to do clean work 
in the immediate neighborhood of the tissue treated. 

If, instead of dealing with an affection limited to a 
few glands, we have an extended surface affection, we 
can make use of another instrument devised by Koll- 
mann. It consists of a hollow hard rubber cylinder 
(Fig. 46), about 10 cms. in length. The walls of the 
cylinder are pierced by rows of small holes. The 
distal end of the instrument is provided with an olive- 



VARIOUS STAGES OF GONORRHEA. 135 

shaped tip, which prevents the solution from flowing 
farther back in the urethra than is intended. The 
proximal end of the instrument is conical in shape, for 
the purpose of enclosing the urethra in front. Inside 
of this rubber cylinder is a metal tube, which is con- 
nected with the electric current at its proximal end. 
The instrument is introduced and an aqueous solution 
or preferably a physiologic salt solution is injected and 
the urethra distended. The fluid is prevented from 




Fig. 46. 

returning by a stop-cock at the proximal end of the 
metallic tube. The negative pole of the battery is 
attached to the instrument, and the positive pole is 
placed over the symphysis. 

The current is turned on gradually to 1.5 to 2.5 
milliamperes. The duration of the exposure is about 
five minutes. The electrolysis takes place through 
the holes of the instrument and the surrounding liquid 
in a much more mild manner than is the case with 
Kollmann's sound. The electrolytic action can be 
seen on the mucous membrane in the form of round 
red spots. The instrument was primarily not intended 
for this purpose. It ought to serve as an indifferent 
electrode for intraurethral galvanization in cases of 



136 TREATMENT OF GONORRHEA. 

neurosis. When the instrument is used for this purpose, 
the urethra must be well ballooned out with water and 
kept so until the end of the treatment, The spots 
mentioned above are not allowed to appear on the 
mucous membrane. The instrument is connected 
with the positive pole and the application should not 
last longer than two minutes. 

This form of electroylsis is not used very much for 
the reason that dilatation and irrigation bring about 
the desired results more quickly. 

Incision of the inflamed crypts and glands with a 
small endoscopic knife and the subsequent cauteriza- 
tion with nitrate of silver or chromic acid crystals liq- 
uefied on the end of a urethroscopic sound has not 
yielded particularly encouraging results. The incision 
of follicles which stand out like great bubbles is to be 
recommended. 

It is very important to remember that the anterior 
urethra must be healed before any permanent improve- 
ment of the posterior urethra and its adnexa can take 
place. As long as the anterior urethra is affected, rein- 
fection of the posterior urethra may occur at any time. 
Relapses are not as common in the posterior urethra as 
they are in the anterior urethra, where glands are more 
abundant and better developed. The treatment of a 
relapse does not differ in any way from that of the 
original affection. The knowledge gained in the treat- 
ment of the original affection is a great aid in the treat- 
ment of a relapse. 



VARIOUS STAGES OF GONORRHEA. 137 

SPECIAL THERAPEUTICS OF THE POSTERIOR 

URETHRA. 

Hard infiltrations of the anterior urethra are, as 
a rule, accompanied by the same pathologic changes 
in the posterior urethra. Long-standing affections 
of the posterior urethra usually are not limited to the 
mucous membrane. They extend deeply into the 
tissue, attacking the excretory ducts of the sexual glands, 
and through these the prostate, the seminal vesicles, 
and, perhaps, the epididymis. Treatment of the pos- 
terior urethra must, therefore, include treatment of the 
seminal vesicles, the sexual glands, and their excretory 
ducts. 

The infiltration may be limited to the colliculus sem- 
inalis, the ejaculatory ducts, or the prostatic ducts, the 
superficial mucosa, or it may extend deeply into the 
submucous tissue. The infiltrations and the second- 
ary contraction of their connective tissue fibers may 
produce stiffness of the walls of the affected ducts. 
The lumen is narrowed or may be closed up entirely; 
or it remains wide open and a spermatorrhea or pros- 
tatorrhea may result. 

Neither the acute nor the chronic gonorrheal process 
is arrested by the vesical sphincter. Either of these 
processes may spread into the bladder and affect the 
trigonum. The affection is usually most marked at the 
neck of the bladder. The cystoscope shows the mucous 
membrane of the trigonum reddened and swollen and 
bulging, or reddened only in spots, and in some instances 
it is covered with follicular excrescences or a delicate 



138 TREATMENT OF GONORRHEA. 

network of vessels. The surface of the mucous mem- 
brane is covered with dead epithelial scales, and a puru- 
lent secretion which appears in the urine or in the irri- 
gating fluid in the form of threads or filaments. The 
fluid is also rendered turbid. 

In treating the posterior urethra we cannot avoid 
treating the bladder as well. A posterior urethritis 
may exist without being manifested by any subjective 
symptoms, but if these are present their severity bears 
no relation to the nature or extent of the pathologic 
changes. The posterior urethra must be examined 
as soon as possible. 

After examining the anterior urethra with the ure- 
throscope, it may be well to sound and catheterize the 
posterior urethra and the bladder. This exploration 
will reveal stronger infiltrations and painful spots. 
Slight bleeding caused by the introduction of a catheter 
is a symptom of superficial inflammation and loosening 
of the mucous membrane. The diagnosis must be 
based on the glass test, an examination of the prostate, 
and the urethroscopic findings. 

It is advisable to treat the posterior urethra for some 
time with dilatations and irrigations before urethroscopy 
is attempted. Bleeding is then much less likely to inter- 
fere with an accurate examination. The treatment of 
the posterior urethra should be commenced at the 
same time as the treatment of the anterior urethra. In 
fact, it is perhaps best in every case to treat the 
entire urethra and bladder. A contraindication to 
instrumental treatment of the urethra is an acute in- 



VARIOUS STAGES OF GONORRHEA. 139 

flammation of the adnexa, such as prostatitis and 
epididymitis. 

The dilatation of the posterior urethra is done mostly 
with instruments which dilate only with their curved 
portion. Oberlaender uses instruments that have the 
Guyon curve, while Kollmann prefers the Dittel curve. 
Both kinds appear to give good results, but the Guyon 
curve corresponds more nearly to the natural anatomic 
condition present. 

Catheters or sounds with the same curve as a dila- 
tor may be used before the latter is introduced, in order 
to map out the course of the urethra. Kollmann and 
Oberlaender do not think it advisable to introduce 
several such instruments in one sitting, especially when 
there is disease of the adnexa. In order to produce 
special action on the colliculus, the dilator is depressed 
to nearly the horizontal line. If it is intended to dilate 
the membranous urethra, the instrument is raised to 
nearly an angle of 45 degrees. A more accurate locali- 
zation can be obtained by palpating through the peri- 
neum and rectum. 

The first dilatation should be done carefully, especi- 
ally if an acute inflammation has just subsided, or 
if the introduction of the instrument causes pain. 
Observe the expression on the patient's face while 
dilating, and stop at once if any suffering is occasioned. 
Cocainization of the posterior urethra prior to dilata- 
tion is not to be recommended, because it is not very 
effective in this region. The first dilatation should not 
be increased beyond twenty-five Charriere, and if the 



i 4 o TREATMENT OF GONORRHEA. 

introduction of the instrument was attended by pain, it 
is best not to dilate at all, simply allowing the instru- 
ment to remain in the urethra undilated for about five 
minutes. The same procedure is followed when there 
is reason to believe that the urethra has been injured 
by the introduction of the instrument. 

The increase in the dilatations of the posterior urethra 
should be slow, especially at first. It is by no means 
necessary to increase the dilatation in each succeeding 
sitting. An increase of one number every second or 
third treatment usually is sufficient. The reactions 
are treated in exactly the same manner as was described 
in the case of the anterior urethra. Any increase in the 
quantity of the discharge is manifested by an increased 
cloudiness of the urine. 

If separate dilatation of the anterior and posterior 
portions of the urethra is demanded, it is advisable to 
dilate the anterior urethra first and the posterior about 
four or five days afterward. In proper cases we may 
use dilators which dilate anteriorly as well as posteriorly. 
The isthums reacts very well to the dilatations. A four- 
branch dilator is better than one with only two or three 
branches. The action of the dilatations should be 
uniform in order to prevent the concentration of irrita- 
tion in certain places. This is the surest way to prevent 
unexpected reactions. The healing of the posterior 
urethra takes place quickly in simple affections of the 
mucosa, but is comparatively slow in occurrence if the 
excretory ducts of the sexual glands are involved. A 
long course of treatment accompanied by relapses is 



VARIOUS STAGES OF GONORRHEA. 141 

the rule in these cases. Even after the symptoms have 
disappeared the treatment should be continued in a 
mild form for some time. 

The symptoms of an affection of the bladder tend to 
disappear early in the course of the treatment. When 
this does not occur, a careful search should be made 
for the causes of such obstinacy. Repeated careful 
cystoscopic examinations may reveal concretions in 
the bladder, tuberculosis, etc., or catheterization of the 
ureters will show the process to have extended to the 
ureters. As a rule, the prostate gland is the last part 
of the genitourinary tract to undergo healing. 

Before beginning the treatment of a relapse, the affec- 
tion must be localized carefully. The longer the time 
that elapses before the relapse makes its appearance, 
the more careful must we be in resuming graduated 
dilatation. Remember that the affection in the anterior 
urethra is the cause of a relapse in the posterior urethra. 

TREATMENT OF HARD INFILTRATIONS OF THE 

THIRD DEGREE. 

To this group belong all the hard infiltrations which 
after a few dilatations cannot be passed by a urethro- 
scopic tube of No. 23 Charriere. The typical cases of 
this class show extended narrowing of the lumen of the 
urethra which is produced by the deeply penetrating, 
coarsely-formed infiltrations which resist absorption by 
dilatation. 

The clinical picture of the hard infiltrations of the 
third degree is a varied one. In one person a strongly 



142 TREATMENT OF GONORRHEA. 

developed stricture may occasion symptoms suggestive 
of a mild chronic gonorrhea, while in another there may 
be a continued discharge of pus, constant bladder 
trouble, retention of urine, and sexual neurasthenia. 
Neither the subjective nor the objective symptoms are 
such as to permit of drawing conclusions as to the 
severity of the pathologic lesions present. 

In examining these cases it is often of value to note 
the condition of the urinary stream. It is, therefore, 
best to get the patient into the habit of urinating before 
each treatment. In strongly developed infiltrations the 
stream is thin, spiral in shape, and interrupted. This 
is especially true when the infiltrations are located in the 
anterior urethra. The examination is begun with a 
bougie a boule. It is sometimes necessary to try several 
sizes before one will pass all the strictures and enter 
the bladder. The bougie a boule olivaire produces the 
least injury, but the information gained is obtained only 
from the region of the strongest infiltrations. The in- 
troduction of conical metal sounds and catheters gives 
some information as to the hardness and resistance of 
the narrowest parts. 

The urethrometer is of little diagnostic value in these 
cases. It does not give any more information than the 
bougie a boule, and its use is limited to the anterior ure- 
thra. The bougie a boule, on the other hand, searches 
the entire urethra. The exact condition of the lesions 
present can only be ascertained by means of urethroscopy 
when this is possible. The five-glass test is unreliable 
in these cases, on account of the narrowness of the ure- 



VARIOUS STAGES OF GONORRHEA. 143 

thra, which causes the solution to flow into the bladder 
instead of allowing it to return to the meatus. 

With the aid of the two-glass test, we usually are in a 
position to determine whether the bladder is affected. 
By means of cultures and the use of the miscroscope, 
we can determine the nature of the infection. A cul- 
ture should always be made if the case reacts with fever 
and chills to the instrumental treatment. Some informa- 
tion may also be obtained by palpating the prostate, but 
the secretion expressed is usually prevented from appear- 
ing at the meatus by the narrowness of the urethra. 
The narrow parts may also make irrigation difficult, 
and internal medicines like salol and oil of sandalwood 
must be given instead. 

1$ Olei santali, 5ij. 

Salolis, 3j. 

Ft. caps, xxiv, four to six a day. 

In cases showing only a slight catarrhal infection and 
where complications are not apparent, the dilatation 
treatment is begun at once. In cases where caution is 
necessary, it is best to start the treatment with elastic coni- 
cal bougies, introduced every third to eighth day, and left 
in place for from five to twenty-five minutes each time. 
Kollmann uses bougies filled with shot or fine lead filings, 
but these bougies cannot be obtained in sizes lower than 
No. 8 Charriere. When there is great narrowing of 
the urethra, he uses elastic bougies, with a zinc or a 
copper wire in the center. The French manufacturers 
quite recently put on the market silkworm gut in the very 
finest filiform bougies. The patient is always asked to 



i 4 4 TREATMENT OF GONORRHEA. 

urinate before the instrument is introduced, and in se- 
vere cases irrigation with boric acid should precede the 
sounding. 

The size of the bougie should be increased only after 
it has been resting loosely in the stricture for several 
treatments. It is not advisable to increase the dilata- 
tion beyond 20 Charriere with the elastic bougies, be 
caus if the patient has stood the previous treatments 
well, we can change to metal instruments at this num- 
ber, or even sooner, without fear of producing an unex- 
pected reaction. Conical metal catheters and sounds 
should be used in every case before the more active 
treatment with dilators is begun. The instrument 
should be well lubricated with a lubricant of solid con- 
sistency such as 

1$ Saponis pulverisati, 3vi. 

Glycerini, Aquae, aa., 3iij. 

Ac. carbolic pur., Trjvii. 

(Guy on.) 

The four anatomic obstructions met with in the poster- 
ior urethra are the (bulbous sac) , the colliculus seminalis, 
the internal sphincter, and the posterior part of the tri- 
gonum. Any other obstruction to the introduction of 
an instrument than those mentioned is pathologic in 
origin. When trying to enter the narrow part of the 
urethra, the instrument should be guided along the nor- 
mal course of the canal. It should not be moved from 
side to side in the attempt to find the natural opening, 
because it is not very likely that the entrance of the 
stricture will be found in this way. The end of the in- 



VARIOUS STAGES OF GONORRHEA. 145 

strument may be pushed into an artificial pouch and a 
false passage made. 

If these rules are observed, some pressure on the 
instrument is allowable. By withdrawing the instru- 
ment a little, one can ascertain whether it has entered 
the stricture. If not, a smaller instrument should be 
tried. If there is much bleeding, a day or two should 
be allowed to elapse before another attempt is made to 
pass the stricture. If there is retention of urine, it 
must be remembered that the passage could not have 
been closed completely at once, because urine passed 
through it some time previously. 

Many of these cases are due to painful tenesmus. 
A warm bath of thirty to sixty minutes' duration and 
a morphine injection of ^ to J of a grain usually will 
give relief. 

In order to remain informed as to the reaction to the 
treatment, the patient should visit the physician on the 
following day. If the stricture is an old and a narrow 
one, it is advisable to keep in touch with the patient for 
from six to eight hours, because during this time there 
is swelling of the mucous membrane and consequent 
retention of urine as the result of the dilatation. The 
parts which are particularly prone to swell are the 
meatus, the end of the bulbous sac and the membranous 
urethra. Dilatation of these parts must, therefore, 
be done with great care. The swelling will disappear 
spontaneously within from six to twenty-four hours. 

In the case of strictures the reactions generally run 
a somewhat severer course than do the reactions 



146 TREATMENT OF GONORRHEA. 

after the treatment of infiltrations of the first and second 
degree. Marked swelling in the latter after dilatation 
is usually a sign of too severe treatment, while in the 
infiltrations of the third degree swelling occurs regu- 
larly. The instrument used last in the preceding treat- 
ment is used first in the next, but in some cases it is 
necessary to begin with smaller sizes. The little success 
each time ought to satisfy the operator. By making 
haste slowly, as is sometimes said, we have less need 
to fear the onset of complications and the more certain 
will be the ultimate success. 

Slight bleeding cannot be prevented in this method of 
treatment without lessening the beneficial effect. It 
is advisable to have the patient stay in the office for a 
quarter to half an hour after each treatment, so that we 
may watch the immediate effect of the treatment. The 
patient should be made to take as much rest as possible, 
and be cautioned against exertions of any kind. If 
we do not succeed in passing all the strictures, after a 
certain number of attempts, and enter the bladder, 
further treatment should be deferred for several weeks. 
In urgent cases surgical intervention must be employed, 
but repeated and careful attempts with the method 
described above will usually prove successful and give 
far better results in the end than can be obtained from 
surgery. In the intervals between the treatments the 
patient is directed to take warm sitz baths once or twice 
a day, for forty-five to sixty minutes each time. These 
baths seem to influence the hardness of the infiltration 
favorably. The greatest difficulties are overcome as 



VARIOUS STAGES OF GONORRHEA. 147 

soon as we succeed in reaching the bladder. The 
bougie is to be withdrawn slowly, the penis being 
pushed back as far as possible at the same time. Ir- 
rigation with boric acid or weak potassium permangan- 
ate solution should be commenced as soon as possible, 
especially when definite catarrhal conditions are present. 

The reaction should be watched carefully. The in- 
strumental treatment should not be repeated until the 
reaction has run its course, which generally takes place 
in from three to fourteen days. Crowding or forcing 
the instrumental treatment produces new spots of in- 
flammation and increases the severity of existing in- 
flammatory areas. 

If there is a discharge from the anterior urethra, 
injections of a 1 to 2 per cent, solution of zinc sulphate 
and alum are indicated. Balsamics may be given to 
aid in reducing the catarrhal condition of the bladder. 
Turbidity of the urine due to bacteria is best treated 
with hexamethylenamin (urotropin). The more in- 
elastic the instrument used in dilating the stricture, 
the smaller should be its size and the less pressure is 
required to obtain a reaction. The most elastic and 
serviceable instruments are the hollow bougies. Next 
in order are the rilled bougies and, finally, come the 
metal sounds and dilators. 

If reasons exist for taking special precautions the 
dilator should be introduced but not opened at the first 
visit. If this treatment has produced the desired re- 
sults, dilatation of one to two numbers may be done at 
the second visit. This dilatation should not be repeated 



148 TREATMENT OF GONORRHEA. 

oftener than once a week. The more apparent the 
purulent nature of the case is, the longer should be the 
interval between dilatations and the shorter should be 
the time the dilator is allowed to remain in the urethra. 
The post-operative swelling should disappear within 
forty-eight hours. The discharge should not be in- 
creased essentially by the dilatation, and the urinary 
stream ought to show a steady improvement. This 
method of treatment consumes considerable time, but 
by this means the hardest infiltrations may be absorbed. 

A condition designated as instrumental fatigue 
sometimes occurs in the case of nervous and irri- 
table patients. The treatment should be discon- 
tinued at once, and not resumed for a month or two. 
When the treatment is taken up again, it must be very 
mild. No rules can be laid down as to the limits to 
which the dilatations may be pushed. In general, it 
may be said that we should dilate until we have a 
healthy surface. In catarrh of the bladder, in bacteri- 
uria, in affections of the pelvis of the kidney and in the 
case of partial or total retention of the urine the injuries 
incident to the dilatation may be very severe. There 
may be chills and fever and an increase in the local 
inflammatory conditions. When the patient has a 
weak heart, the result of a chronic nephritis, one in- 
judicious treatment may prove fatal. If the urine has 
always been clear, and if the general health of the 
patient is good, a dilatation which draws a few drops of 
blood need cause no apprehension. 

Callosities also yield to the dilatations if they are 



VARIOUS STAGES OF GONORRHEA. 149 

acted on by the instrument, but if they get between the 
branches of the dilator, the dilatation will affect the 
healthy tissue only. This occurs most often in the 
bulbous end of the urethra. If the callosities are ar- 
ranged circularly, resistance is felt on dilatation, and if 
force is used, the dilator will break. 

Even with great patience it may be impossible to in- 
crease the dilatation beyond a certain number. Inter- 
nal urethrotomy is indicated when the callosities are 
located in the anterior urethra, but the posterior urethra 
should never be treated in this way. The best instru- 
ment with which to accomplish this purpose is the old 
two-branched urethrotome devised by Otis (Fig. 26). 
It has the disadvantage, however, that the part to be in- 
cised must be determined by measurement, a very 
unreliable method because the length of the urethra 
varies according to the blood supply of the tissues sur- 
rounding it. Therefore, the incisions are not always 
made in the proper place. 

Kollmann's urethrotome (Fig. 47) consists of a metal 

bougie a boule with exchangeable heads of different 

sizes. By means of an arrangement on the handle of 

the instrument a knife can be thrown out at the height 

of the head. After having chosen a head which will 

pass the stricture, the instrument is introduced and 

under the guidance of palpation its head is passed just 

beyond the stricture. The knife is thrown out and 

with a quick movement the stricture is cut. The 

narrowest stricture that can be cut with this instrument 

is No. 18 Charriere. An elastic filiform bougie can 
11 



IS© 



TREATMENT OF GONORRHEA. 




be fastened to the head for the purpose of passing 
through narrow strictures. The in- 
cision should be made in the middle 
line of the superior wall, because if 
made in any other place considerable 
bleeding may follow. 

The urethra should be irrigated be- 
fore and after making the incision. 
The bleeding may be controlled easily, 
if the incision is not too deep, by ap- 
plying a compression bandage to the 
pendulous urethra. The bandage is 
removed by the patient just before the 
next micturition. There is then no 
more bleeding and the bandage need 
not be applied again. Kollmann 
always uses this ambulant treatment 
and has not had any accidents as yet. 
After the urethrotomy the urethra 
is kept patent by sounds passed once 
or twice every week at first, and every 
month later on. After passing the 
colliculus a metal instrument ought 
to slip into the bladder almost by its 
own weight. Sometimes there are in- 
filtrations or callosities just in front 
of the internal sphincter which ob- 
struct the passage of the instrument. 
Fig. 47- In such cases elevate the handle of 

the instrument a little, and without using force 



VARIOUS STAGES OF GONORRHEA. 151 

introduce the instrument again until the obstruction 
is met. 

The diagnosis of the presence of callosities can usu- 
ally be made in this way, although we may have to do 
with a tonic contraction of the surrounding muscles. 
This may be overcome at the next treatment if the 
patient's bowels are thoroughly evacuated and a warm 
sitz bath of at least one-half hour's duration is ordered 
to be taken just before coming for the next treatment. 
A cocaine suppository in the rectum or cocainization of 
the posterior urethra may also aid in overcoming the 
spasm of the muscles. 

In strictures such as those mentioned it is impossible 
to enter the bladder with a metal instrument, but this 
may be accomplished by means of an elastic bougie. 
The graduated dilatations may be begun with elastic 
instruments. The narrowing that is caused by callos- 
ities usually is not accompanied by any other inflam- 
matory condition of the urethra. The callosities, as 
a rule, are the sequelae of an acute posterior gonorrhea 
which did not become chronic, but formed abscesses. 
If instrumental treatment is begun soon after the acute 
stage has passed, callous formation may be prevented. 

In some instances it may be difficult to differentiate 
between callosities and a large prostatic sinus of Dittel, 
the latter being considered a normal obstruction. If 
the obstruction can be passed by means of an elastic 
catheter, with a single or a double Mercier curve or with 
a metal instrument, using Hey's movement, it is not a 
callosity. In obstinate cases an external urethrotomy 



iS2 TREATMENT OF GONORRHEA. 

must be done and the callosities excised. However, 
the results of such a procedure are not always gratify- 
ing, because excision of the diseased parts of the ure- 
thral wall will not dispense with the necessity of gradu- 
ated dilatations. A stricture can only be absorbed 
when it still contains tissue that will react to the action 
of the graduated dilatations. Fibrous connective tissues 
react with difficulty only. 

PAPILLOMATOUS URETHRITIS. 

In disease conditions, the urethra may contain papil- 
lomatous growths which correspond histologically to 
the warts found on the prepuce. They occur either 
singly or in groups in any portion of the urethra, but 
particularly in the middle of the cavernous urethra. 
These warts usually are caused by gonorrheal infection, 
although Kollmann and Oberlaender have seen cases 
where gonorrhea could be excluded as a cause. When 
the fossa navicularis contains a papillomatous growth, 
warts will usually be found also on the meatus and the 
prepuce. The warts in the urethra can be recognized 
readily by means of the urethroscope and it is impos- 
sible to mistake them for anything else. Each wart 
protrudes prominently into the lumen of the urethra. 
The color of the urethral mucous membrane varies 
from a rose-red to a deep red. If the warts occur 
in groups, a smeary smegma-like substance is found 
between the papillomata. After removal of these 
growths, the supporting tissues suffer a pronounced 



VARIOUS STAGES OF GONORRHEA. 153 

glandular infiltration which, under certain conditions, 
leads to the production of strictures. 

These cases are usually discovered accidentally while 
making a urethroscopic examination. They do not 
manifest themselves clinically by any very pronounced 
symptoms, sometimes none at all other than those 
characteristic of a slight chronic gonorrhea. If these 
warts occur in large groups, subjective symptoms may 
be present and, particularly, disturbances on urination. 

According to Oberlaender, these papillomatous 
growths are not met with as often now as formerly. 
The irrigations and dilatations given in the course of 
treatment of a case of gonorrhea deprive the warts of 
nutrition, they decrease in size, and sometimes fall off 
from the mucous membrane without any special treat- 
ment. In the more obstinate cases they are removed 
after having been brought into view with the urethro- 
scope in the following manner : 

Two pledgets of cotton on applicators are introduced 
up to the papillomata. The urethroscopic tube is then 
withdrawn, the two cotton tampons being left in situ. 
They are brought opposite each other in the region of 
the growth, and moved together to and fro and to the 
side of the attachment of the warts. 

The urethroscopic tube should be of a size as large 
as the caliber of the urethra will permit, and the tampons 
should be just large enough to pass each other in the 
urethroscopic tube. The penis must be well stretched in 
order to prevent the formation of transverse folds. 
These movements either separate or loose the attach- 



154 TREATMENT OF GONORRHEA. 

ments of the warts, and it will be noted immediately 
after the treatment or on the following day that a large 
number of the papillomata have been rubbed off. 

It may be necessary to repeat this procedure several 
times. The interval between the treatments should be 
at least one week long. Of assistance in the removal 
of these growths is powdering them with resorcin, 10 per 
cent., and gum arabic, 90 per cent. 

The excrescences may also be cut off with the edge 
of the urethroscopic tube. This is usually successful in 
the first sitting in the case of the smaller papillomata. 
The larger ones may require two or three treatments 
before they fall off. The very obstinate papillomata 
can be removed with Gruenfeld's cold wire snare or 
with Dittel's endo urethral forceps. Any remaining 
stumps may be treated with the blunt galvano-cautery. 
Papillomata are found in long-standing soft or slightly 
hard infiltrations. These operative procedures are 
applicable to papillomata situated in the anterior as 
well as those in the posterior urethra. Papillomatous 
growths situated near the excretory ducts of the sexual 
glands must be removed carefully and without injuring 
the neighboring structures, because of the possibility 
of extension of the inflammation taking place. Papillo- 
mata situated near the external meatus can sometimes 
be reached with the scissors or the ordinary cautery. 



CHAPTER X. 

BACTERIURIA AND NON-GONORRHEAL 
URETHRITIS. 

This condition is the condition in which freshly voided 
non-purulent urine is made turbid by the presence of 
numerous microorganisms. It occurs in infectious 
diseases other than those of the genitourinary tract, 
but inasmuch as it usually accompanies a chronic 
gonorrhea, it is mentioned in this connection. 

The treatment consists in the administration of urin- 
ary antiseptics, urotropin gr. 7I, t.i.d., and in regulation 
of the bowels. Habitual constipation is often the di- 
rect cause of colonbacilluria. If the cause of the bac- 
teriuria is located in the lower urinary passages, irri- 
gations with potassium permanganate may be of service. 
A faultless technic is absolutely necessary if we would 
not run the risk of producing a septicemia or a pyemia, 
which might terminate fatally, especially in the case of 
older patients. 

CHRONIC NON-GONORRHEAL URETHRITIS. 

This affection stands closest to the soft gonorrheal 
infiltrations. Walsch mentions as characteristic of 
these cases long periods of incubation; chronicity from 
the beginning; causing the patient little inconvenience, 

i55 



156 TREATMENT OF GONORRHEA. 

the gonococcus always absent, and in spite of proper 
treatment healing does not take place. Reichmann 
found hyperemia and granulations affecting especially 
the posterior urethra. He destroyed these granulations 
with the galvano-cautery, stopped the secretion but 
failed to obtain any healing. 

I have obtained satisfactory results in one case by a 
combination of the regular antiseptic and congestive 
treatment with vaccination therapy under guidance of 
the opsonic index.* 

*The determination of the opsonic index were made by Dr. Fischer 
at the Columbus Medical Laboratories. 



CHAPTER XI. 
GONORRHEAL PROSTATITIS. 

Prostatitis is the most important and the most fre- 
quent complication of gonorrhea. In most cases of 
posterior gonorrhea the gonococci find their way 
through the prostatic ducts to the gland. They usu- 
ally perish there without producing an inflammation. 
Goldberg thinks that the prostate gland secretes a sub- 
stance which under normal conditions confers immunity 
to gonorrhea on the gland cells. Infection will occur, 
however, under certain conditions, as in the case of 
masturbators, bicyclists, equestrians, and in persons who 
are given to carousing, and excesses in general. Such 
individuals are the victims of long-continued hyperemic 
conditions and irritations of the prostate gland, and 
offer a favorable soil for the growth of the gonococcus. 
It is not clear why in one case we will have an acute 
abscess with inflammation, and in the other a subacute 
or chronic catarrhal inflammation. 

Prostatitis is a complication in sixty to seventy- 
five per cent, of all cases of chronic gonorrhea. It 
most often accompanies the hard infiltrations of the 
first and second degree, less frequently the soft infiltra- 
tions, and seldom the infiltrations of the third degree. 
Two principal forms can be distinguished, the super- 

iS7 



158 TREATMENT OF GONORRHEA. 

ficial desquamative process, which is limited to the 
excretory ducts of the glands, and a deep, suppurative 
process, which affects the glands themselves. 

The latter is more common than the former. Ober- 
laender is of the opinion that usually only one portion 
of the gland is affected at a time, and that the inflam- 
mation spreads to the other portions gradually, the part 
first affected going on to healing in the meantime. 

The diagnosis is not always easy. The most valua- 
ble information usually is obtained by rectal palpation. 
The normal prostate is of variable form and size. 
A large prostate does not necessarily mean a diseased 
gland, but if both lobes show an essential difference in 
size, the condition usually is a pathological one. If, 
in addition to this, palpation reveals distinctly painful 
spots in one or the other lobe, then there can be no 
question of inflammatory changes. The consistence of 
the normal gland is variable. In some cases it is 
firm and hard, in others soft and elastic, and in still 
others it is doughy. The latter condition should always 
excite the suspicion of the gathering of abnormal secre- 
tions. The consistency of the gland, therefore, is not 
an indication of any pathologic condition. Oberlaender 
often found tightly stretched and uniformly hard glands 
combined with a purulent secretion. It is usually 
possible by means of rectal massage of the prostate 
to express its secretion, which will appear at the meatus 
in the form of drops or large masses. If no secretion 
appears at the meatus, the urethra may be emptied by 
massaging, beginning at the bulb and proceeding to 



GONORRHEAL PROSTATITIS. 159 

the glans. The patient should always urinate before 
the massage is begun, in order to prevent the admixture 
of the urethral and prostatic secretions, which would 
make the examination less reliable. When no secre- 
tion appears at the meatus even after massaging the 
urethra, it is well to have the patient void only a part 
of the urine before the treatment and the remainder 
after the treatment, thus washing out the expressed 
secretion which is in the urethra. The urine containing 
the prostatic secretion is centrifugated and the sediment 
examined microscopically. More accurate results can 
be obtained if the urethra and the bladder are irrigated 
before and after massage. Boric acid or physiologic 
salt solution are most suitable for this purpose. The 
pathologic secretion can be recognized microscopically 
according to Goldberg, as follows: A drop of normal 
secretion placed on a glass plate appears as a uniformly 
milky fluid, while the abnormal secretion appears as an 
incomplete emulsion only. Schlagintweit describes the 
following macroscopic test. The patient is made to 
place his meatus over a glass of water while the operator 
massages the prostate. The prostatic secretion dropping 
into the glass is dissolved by the water and imparts to 
it an opalescence; while the pus falls to the bottom of 
the glass. The contents of the seminal vesicles (ex- 
pressed secretion of the upper part of the prostate) does 
not dissolve. The secretion sinks slowly to the bottom 
of the glass, leaving a trail behind it in the form of a 
column, which connects the drop with the surface of 
the liquid. 



i6o 



TREATMENT OF GONORRHEA. 



The most reliable aid in diagnosis is the microscope. 
The normal secretion of the prostate consists of masses 
of lecithin granules and some glandular epithelial cells 
(Fig. 48). The spermatic crystals and the amyloid 
corpuscles are not constant ingredients of the prostatic 
secretion. The presence of spermatozoa in the secre- 
tion usually means an involvement of the seminal vesicle 
and ejaculatory ducts in the inflammatory process. 




Fig. 48. — Microscopical appearance of the semen (human) eye-piece 
III., objective 8a, Reichert. a. Spermatozoa; b. Columnar epithelium 
cells; c. Bodies enclosing lecithin granules; d. Squamous epithelium 
cells from the urethra; d. Testicle cells; e. Amyloid corpuscles; /. Sper- 
matic crystals; g. Hyaline globules, (von Jaksch.) 

The symptoms of gonorrheal prostatitis are extremely 
variable and not infrequently a typical purulent prosta- 
titis will run its course without being recognized. The 
symptoms are either trifling and so insignificant that 
the patient pays no attention to them, or they manifest 
themselves in the form of a sexual neurasthenia which 
often is not looked on as being in any way connected 
with the prostatitis or the gonorrhea. It is often very 
difficult to make such patients understand that their ner- 
vous affection cannot be cured as long as the treatment 
of its cause is neglected. 



v 



GONORRHEAL PROSTATITIS. 161 

The prostate gland is situated at the crossing of three 
tracts, the urinary, the genital, and the intestinal. Con- 
sidering for a moment the anatomic and physiologic 
relation of the prostate to other organs will make it 
apparent that disturbances due to inflammation of 
this structure give rise to a symptom-complex variable 
in nature and depending on the extent to which one or 
the other tract is involved in the disease process. The 
symptoms may be referable to the urinary, the sexual or 
the digestive tract, and the tract itself may manifest 
symptoms of either motor, sensory, or secretory disturb- 
ances. Exhaustion or depression in one tract may be 
accompanied by over stimulation or irritation in another. 
It is therefore almost impossible to enumerate all the 
symptoms of a prostatitis. 

The patient may suffer from frequent nocturnal 
erections and premature ejaculations, with partial 
or complete sexual impotence. There may also be pres- 
ent disagreeable sensations during and after urination. 
The frequency of urination is usually increased. Other 
disturbances appear to be purely local in character and 
nervous in origin, such as pain in the testis, pain along 
the course of the spermatic cord, accompanied by pain 
on the inner side of the thigh and pain above the symphy- 
sis; pain in the loin, either constant or only after defeca- 
tion, compression and lasting pain of the anus. As 
disorders of a nervous character may be mentioned 
constipation, pain in the abdomen and along the spine, 
headache, a feeling of tire of the body with utter fatigue 
of the limbs, psychologic depression, pain referred to the 



162 TREATMENT OF GONORRHEA. 

piles, pains like those met with in epididymitis and 
inflammation of the spermatic cord. As in the case of 
gonorrhea of the urethra, the severity of the pathologic 
lesion must not be judged or measured by the degree of 
severity of the subjective symptoms. 

Prostatorrhea and spermatorrhea are almost constant 
objective symptoms. If the gland secretes strongly, 
and if the urethra is small in caliber, with few folds, 
there may be present a transient or constant discharge 
of prostatic secretion which is usually mixed with sper- 
matic fluid. The cases met with most often are those 
in which the secretion is pressed out during micturition 
or defecation (prostatorrhea and spermatorrhea), or the 
secretion may appear in the form of filaments in the 
urine. It is difficult to differentiate between prostatitis 
and vesiculitis. 

The differential diagnosis between chronic gonorrhea 
of the urethra and the gonorrheal infection of the pros- 
tate cannot always be made. The secretions may inter- 
mingle or the prostatic secretion flows into the bladder, 
producing a turbid, purulent urine, or a clear urine, 
containing filaments. 

It is not uncommon to have a strong purulent flow 
containing gonococci in great numbers during the course 
of a prostatitis. In such cases the cause is usually the 
rupture of an encapsulated prostatic abscess. Under 
suitable treatment, such as massage of the prostate and 
irrigation of the urethra and bladder, the gonococci dis- 
appear in a few days. The pus thins out and becomes 
less in quantity, until after about nine or ten days the 



GONORRHEAL PROSTATITIS. 163 

urethra is dry and the urine clear. A urethroscopies 
examination at this time may not reveal any changes 
in the mucous membrane. 

If the purulent prostatic discharge flows into the 
bladder, a clear urine will suddenly become turbid. 
With the aid of rectal palpation it is sometimes possible 
to discover the cavity of the abscess. Pressure with 
the finger will force the remaining pus into the urethra. 
In most cases the pus is blood-stained, and cases are 

observed where pure blood is discharged after mic- 
turition. 

Prostatitis and posterior urethritis must always be 
taken into consideration as possible causes of hemat- 
uria. Prostatitis may also be the cause of a bacteriuria. 
The prostatic bacteriuria yields promptly to massage 
and irrigation, but renal bacteriuria does not. 

Phosphaturia appears as a symptom of prostatitis 
in a considerable number of cases. The color of the 
urine varies from a light green shade to a milky turbidity. 
The addition of acetic acid clears the urine and brings 
the gonorrheal filaments into view. The presence of 
filaments is a valuable symptom in the differential diag- 
nosis of " essential phosphaturia." Phosphate of cal- 
cium mixed with smaller or larger quantities of carbon- 
ate of calcium sometimes is seen in prostatic phosphat- 
uria in the form of whitish crumbling masses at the 
end of urination or in the last portion of urine voided. 
The discharge is usually accompanied by a burning 
spasmodic pain at the neck of the bladder. 

The causes of phosphaturia in this affection are the 



i6 4 TREATMENT OF GONORRHEA. 

alkaline decomposition of the urine, the vegetable diet, 
and alkalies contained in the medicines. The con- 
dition disappears with the healing of the underlying 
affection. Albuminuria in connection with prostatitis, 
with an absence of large amounts of pus or of sper- 
matozoa, usually is traumatic in origin and transitorv 
in character. 

The differential diagnosis from senile hypertrophy 
of the prostate is aided by the age of the patient, the 
presence of recidual urine, and, perhaps, by the absence 
of pus in the expressed secretion. In advanced hyper- 
trophy, when the catheter must be used constantly, 
the prostate is congested and the disturbances caused 
thereby are very similar to those of a gonorrheal infec- 
tion. 

The differential diagnosis from tuberculosis of the 
prostate is very difficult at first, and can only be made 
by finding the tubercle bacilli. In tuberculosis, the 
urine does not clear up with irrigations of nitrate of 
silver; in fact, the condition is sometimes made worse 
rather than better. The same is true of massage and 
dilatations. 

The prognosis of gonorrheal prostatitis depends in 
a measure on the course and healing of the coexisting 
gonorrhea. As long as the gonorrhea is not cured, a 
healing of the affection of the prostate cannot be ex- 
pected, on account of the constant reinfection from the 
urethra. 

The time required to cure a case of prostatitis varies 
from several months to several years. It is best to 



GONORRHEAL PROSTATITIS. 165 

continue the treatments for two or three months, and 
then suspend them for a month or two at first, and 
three or four months later on. The treatments should 
always be mild. 

Gonococci are not always found readily in this affec- 
tion. Notthaft found that one-fourth of all cases of 
prostatitis show evidences of secondary infection within 
the second half of the first year. He mentions the fol- 
lowing germs found in cases of secondary infection in 
the order of their frequency: (1) Staphylococci; (2) 
diplococci, staining by Gram's method; (3) bacilli; 
(4) streptococci; (5) unidentified bacteria. 

These mixed infections complicate the treatment 
and make the prognosis uncertain. Chills and high 
fever may occur in these cases, without apparent cause, 
or in response to slight irritation of the urethra by instru- 
mental or even medicinal treatment. They may be 
present irregularly for weeks or even months. In 
severe cases the outcome may be a fatal one. The 
attacks are best treated by means of hot applications 
to the abdomen. They dispel the pain by producing 
an increase in the congestive hyperemia and promoting 
the gathering of pus into abscesses. Urinary anti- 
septics should be given internally, but we must not 
expect too much from them. 

As a rule, the abscesses rupture spontaneously into 
the urethra, less often into the rectum. If an abscess 
fails to rupture, and if the patient's condition is poor 
by reason of the intoxication, it is advisable to evacuate 

the abscess by perineal — pre-rectal — incision. It is not 
12 



166 TREATMENT OF GONORRHEA. 

advisable to open the abscess through the rectum even 
when rupture of the abscess in that direction is 
imminent. 

Post-mortem examinations have shown that some- 
times the entire prostate gland is converted into an ab- 
scess, which is encapsulated, without giving rise to any 
symptoms. On the other hand, such an abscess may 
be the cause of a pyemia which appears suddenly, and 
results fatally, without a diagnosis of the cause of death 
having been made. 

In the treatment of this affection it is well to remem- 
ber that the immediate cause of the infection was a 
posterior urethritis, and that the microorganisms 
entered the gland through the prostatic ducts. There- 
fore, treatment should first be directed to the portal 
of entrance of the infection. 

In the acute stage, the treatment consists in irriga- 
tions only, while in the chronic stage it consists of 
irrigations and dilatations. The graduated dilatations 
first absorb the infiltrations around the ducts, next 
those in the interior of the gland. Instruments with 
Guyon's curve should be used in preference to those 
having a Dittel's curve. 

The inflammations of the prostate and those of the 
bulb have many points in common. In both affections 
inflammation involves the deeper tissues so that they 
are not easily acted on by the dilatations. These foci 
of infiltration are resistant to treatment, and display 
a tendency to spread toward the urethra and, under 
certain conditions, to produce exacerbations. 



GONORRHEAL PROSTATITIS. 167 

Irrigations and dilatations are conducted according 
to the same rules as in affections of the urethra. Dila- 
tations are made every ten to fourteen days, irrigations 
every day or every other day, and massage of the pros- 
tate once or twice a week. The progress of an unevent- 
ful healing is best judged by the changes in the urine. 
This is clearing up and the filaments become more 
and more apparent. At first, they are long and thick 
and opaque, and later, and as healing progresses, they 
become shorter and thinner and transparent. 

After each dilatation there is a characteristic change 
in the filaments. They appear in larger numbers, 
but are smaller in size and more friable in nature. In 
the course of a few days they are replaced gradually 
by a smaller number of larger filaments. Later in the 
course of the treatment the filaments are absent for 
longer or shorter periods of time. The filaments con- 
sist mostly of large round cells. Sometimes globules 
looking like fat droplets are seen in the cell body and 
sometimes free in the urine (hyaline globules). 

Healing does not always proceed as smoothly as 
has just been described. Relapses are the rule rather 
than the exception in the course of healing of prosta- 
titis. If a relapse occurs, the dilatation must be com- 
menced again, starting with a low number. 

The treatment of a reaction is identical with the 
treatment of the urethra. Potassium permanganate 
is used first and then sulphate of zinc and nitrate of 
silver in gradually increasing strengths. If the patient 
cannot bear the nitrate of silver solution, or if the 



i68 



TREATMENT OF GONORRHEA. 



urine does not clear up under its use, the zinc sulphate 
or potassium permanganate must be substituted. After 
several weeks the silver nitrate may again be tried. 

An instrument of value in the intraurethral treat- 
ment of prostatitis is the cooling sound or cooling cathe- 
ter of Winternitz (Fig. 49). It consists of a double- 
barreled catheter closed at its upper end. The catheter 
is introduced into the urethra and from five to seven 
liters of water, of proper temperature, are allowed to 
flow through it from a height of about one meter. This 
relieves the symptoms of irritation that accompany 
chronic gonorrhea and prostatitis and the so-called 




Fig. 49. — Cooling catheter of Winternitz. 



post-gonorrheal disturbances. Its use is contraindicated 
in the acute affections of the urethra or of its adnexa, 
in bacteriuria, and in suppurative conditions of long 
standing. The temperature of the water used should 
be 1 5 to 20 Celsius at the first treatment, and lowered 
gradually in subsequent sittings. The instrument is 
removed as soon as the patient complains of cold sen- 
sations. The length of time the instrument is left in the 
urethra varies from 10 to 20 minutes. The treatment 
is repeated two or at most three times a week. It is 
beneficial in spermatorrhea, and prostatorrhea, and 



GONORRHEAL PROSTATITIS. 169 

particularly in nocturnal emissions and in partial or 
total sexual impotence due to prostatitis. 

Warm or hot sounds can be used with benefit in all 
painful conditions of chronic prostatitis. The tempera- 
ture of the water used should be about 40 to 45 Celsius. 
Each treatment is of from ten to twenty minutes' dura- 
tion, and may be preceded by rectal massage. It can 
be repeated two or four times a week. 

Treatment may also be carried out through the rec- 
tum, although only the peripheral portions of the gland 
are influenced. The treatment consists of massage 
and drugs administered in the form of suppositories. 
The massage is the more important of the two. It is 
carried out best with the protected index ringer and is 
to be preferred to massage done with an instrument in 
susceptible cases and where the point of the finger can 
reach the upper border of the lobes. 

Massage is very disagreeable to some patients, on ac- 
count of the pain caused by the palpation of the gland, 
and in consequence of the stretching of the anal and 
rectal sphincters. Reflex contraction of these muscles 
may even make massage impossible. The action of 
the massage is not confined to the emptying of the 
gland of its pathologic secretion. It also improves the 
circulation of the gland. 

The massage is performed with the patient either in 
the recumbent or in the bent upright posture. The folds 
of the anus are well spread apart before the finger is 
introduced into the rectum in order to avoid pressing 
on hemorrhoidal nodes when these are present. If 



170 TREATMENT OF GONORRHEA. 

these nodes are acutely inflamed, the examination 
and treatment should be postponed and the hemor- 
rhoids treated first. 

The first structure felt after passing the anal ring is 
the membranous urethra. It is located in the middle 
line toward the front. Higher up and to the right and 
left of the middle line are the lobes of the prostate 
gland. On the upper border of the prostate, toward 
the outer side of each lobe, can be palpated a shallow 
recess, the seminal vesicles. The fundus of the bladder 
can be felt in the middle line between the seminal ves- 
icles. The movements of the massage are made from 
the border of the gland towards its middle, and consist 
of from four to eight rubbing, kneading and pressing 
movements. The kneading movements are made 
with the tip of the finger; the pressing movement with 
the whole finger. All these movements are made 
slowly. When the prostate is tender, these movements 
must be very gentle. Painful spots must be looked 
for and their position noted. Besides the finger, especi- 
ally devised instruments are used for this purpose. 
The use of these instruments is indicated in the case 
of patients who have a strongly developed panniculus 
adiposus of the buttock. In these cases the finger is 
introduced with difficulty. 

The instrument is also used when the prostate is 
located high up, so that it cannot be reached with the 
finger. A very serviceable instrument for this purpose 
is the one described by Feleki (Fig. 50). Massage 
of the prostate should always be done by the beginner 



GONORRHEAL PROSTATITIS. 



171 



with the finger before using an instrument. The result 
of the first massage often is only a little or no pus at 
all even when the symptoms present indicate an in- 





Fig. 50. — Feleki's massage 
instrument. 



Fig. 51. — Schoenfeld 
psychrophore. 



fected prostate. In these cases the diagnosis is usually 
confirmed by the second or third massage, when a dis- 
tinct purulent discharge makes its appearance. 



172 TREATMENT OF GONORRHEA. 

When the patient is predisposed to develop epididymi- 
tis, the massage should be done very gently and care- 
fully and at longer intervals. The region of the semi- 
nal vesicles should not be massaged at all. In these 
cases we may be forced to limit the treatment to the 
application of drugs to the rectum In uncomplicated 
cases prostatic massage should be given two or three 
times weekly. The patient should feel better after 
each treatment. The Schoenfeld prostatic psychro- 
phore (Fig. 51) is used with great benefit in some cases 
of acute and chronic prostatitis. With this instrument 
we can apply heat or cold in the same treatment by 
turning the cock at the proximal end of the instrument. 

Another very active means of treating these prostatic 
disturbances is the ichthyol injection first used by 
Scharff. Five grams of a five to ten per cent, solution 
are applied to the rectum above the prostate. The in- 
jection is best made just before the patient retires for the 
night. In some patients the application causes tenes- 
mus and then it must be either temporarily or perman- 
ently discontinued. If there is no apparent improve- 
ment after two or three weeks of continued use of the 
ichthyol injections, they must be discontinued. If 
improvement continues, the injections may be continued 
for one or two months. 



CHAPTER XII. 
GONORRHEAL EPIDIDYMITIS. 

Although we are concerned only in the discussion 
of that form of epididymitis which is a complication of 
gonorrhea, we will at this time mention briefly the 
other varieties. 

Acute epididymitis can be divided into a traumatic, 
a metastatic, and a urethral form. The traumatic 
form occurs after forced exercise of the abdominal 
muscles, such as takes place during heavy lifting, jump- 
ing, and the playing of wind instruments. It also 
occurs in equestrians, bicyclists, boxers and wrestlers, 
when it is due to contusions. The metastatic form 
occurs during acute infectious diseases, such as mumps, 
influenza and typhoid fever, but it does not accompany 
these affections as often as does orchitis. 

The urethral form of epididymitis is the most im- 
portant of the three. It is caused by an irritation of 
the urethra which enters the epididymis by way of the 
vas deferens. Inflammation of the vas deferens, to 
the extent of being manifested clinically, is not a neces- 
sary concomitant. The microorganisms were depos- 
ited either on the healthy mucous membrane of the 
urethra at the same time that the irritation occurred, 
or previously, as is the case in a posterior gonorrheal 

i73 



174 TREATMENT OF GONORRHEA. 

urethritis. The last-named condition is the cause of 
the most important and also the most frequent form 
of epididymitis. As immediate causes may be men- 
tioned venereal and other excesses, habitual sexual 
excitement, exertions incident to walking, riding, danc- 
ing and bicycle riding, and occasionally the instru- 
mental treatment of chronic gonorrhea, although this 
may by no means be the fault of the operator. 

Epididymitis may follow prostatic massage. The 
etiologic connection between the two is evident, even 
though previous massage was not followed by this com- 
plication. Other conditions which predispose to the 
production of epididymitis are excessive urethral secre- 
tion, spermatorrhea, chronic inflammations of the 
ejaculatory ducts, and of the vas deferens. Some 
patients exhibit an inclination to relapses a long time 
after the first inflammation has run its course, without 
apparent cause, without instrumental intervention, and 
without previous massage of the prostate, an epididy- 
mitis appears, even after the lapse of months follow- 
ing an apparent cure. It must be assumed that the 
gonococci have lain dormant in the tissues of the adnexa 
and that as the result of some alterations in the cul- 
ture media the conditions for growth again became 
favorable. 

The epididymitis of an acute gonorrhea usually is 
sudden in onset. The patient says that he first had a 
sensation as of a drop of hot water falling on the scro- 
tum, and that this was followed immediately by pain 
and in the course of a few hours swelling of the epididy- 



GONORRHEAL EPIDIDYMITIS. 175 

mis. The epididymitis that follows a chronic gonor- 
rhea is usually gradual in onset and less stormy in its 
course. The first symptom may be pain on pressure 
on the epididymis, and a feeling of weight in the testis. 
On the other hand, chronic gonorrhea does not in- 
sure against the occurrence of a very severe inflamma- 
tion of the epididymis, one which may be accompanied 
by chills and fever, vomiting and convulsions. 

The course of an epididymitis may be divided into 
three stages, the progressive, the stationary, and the 
retrogressive, each stage enduring for three to eight days, 
according to the severity of the case. The severity of 
the symptoms varies with the intensity of the inflamma- 
tion of the epididymis and the extent of involvement 
of the spermatic cord and the seminal vesicles. In 
severe cases there may be marked peritoneal irritation, 
high fever, and much pain referable to the affected 
parts. 

TREATMENT. 

The patient should be at rest, in bed. The ambu- 
lant treatment is not to be recommended, but it must 
be used when the patients are not willing or able to stop 
working. The treatment consists in the application of 
hot compresses, saturated with a one per cent, solution 
of acetate of aluminum. The compress is covered by 
a well-fitting suspensory. If the infiltration and pain 
increase in severity in spite of this treatment, rest must 
be insisted on. 

The scrotum is elevated and hot or cold applications 



176 TREATMENT OF GONORRHEA. 

are applied. Oberlaender and Kollmann prefer cold to 
heat. They cover the scrotum with an ice-bag, which 
is left in place both day and night at first, but later only 
in the daytime. This treatment is continued until 
palpation of the affected parts no longer produces pain. 
According to these authors, a change from cold to heat 
is indicated only when cramp-like pains are present, 
either in the epididymis or in the spermatic cord, or 
if some parts of the swelling remain painful for a long 
time, and if they convey the impression that pus is form- 
ing. It is rare indeed that abscess formation takes 
place in this condition, that is, to the extent of requiring 
surgical intervention. 

The writer prefers to begin the treatment of epididy- 
mitis with the application of heat in the form of poul- 
tices, changing to cold if the pain and swelling do not dis- 
appear within a few days. After the cessation of the 
pain, and when the swelling is reduced, the patient 
may be allowed to move gradually. The application 
of moist compresses after the patient is in condition to 
leave his bed hastens complete absorption of the re- 
maining infiltration. In the more obstinate cases oint- 
ments may be used instead of compresses. Oberlaender 
and Kollmann recommend the following formula: 

1$ Unguentum hydrargyri, dil. (i6| %), 10 parts. 

Extract, belladonnae, i part. 

A portion of this ointment of the size of a pea is 
rubbed in gently two or three times a day. This oint- 
ment is less irritating and less likely to produce an 



GONORRHEAL EPIDIDYMITIS. 177 

artificial eczema than is iodine ointment, which is used 
very much, and gives fairly good results. If an ec- 
zematous condition is produced, the ointment should be 
discontinued at once, the scrotum cleansed thoroughly, 
and compresses applied again. The products of the 
inflammation are absorbed by this treatment. The in- 
duration at the head of the epididymis is usually the 
last to disappear. 

In cases of bilateral epididymitis the patient should 
be informed that sexual impotence may follow the affec- 
tion. Cases have been observed where, in spite of the 
bilateral induration, sterility was not produced. 

During the course of the epididymitis, the treatment 
of the urethra and prostate should either be discontin- 
ued entirely, or continued in mild form only. The 
physician whose experience has been limited will do 
well to discontinue the treatment for at least fourteen 
days and then commencing it again in mild form. The 
irrigations should be resumed first, and then the instru- 
mental treatment. If the epididymitis relapses, in 
spite of careful treatment, it is advisable to give the 
patient another rest for a month or two. The treat- 
ment when taken up again is limited to the anterior 
urethra, being extended to the posterior urethra later 
on, and finally to the prostate. 

Chronic gonorrheal epididymitis is characterized by 
a connective tissue hyperplasia following the acute 
inflammation. There is produced a nodular enlarge- 
ment of the epididymitis accompanied by contractions, 
compressions and even total obliteration of the lumen 



178 TREATMENT OF GONORRHEA. 

of the epididymis. This newly formed tissue must, 
at first, have some circulation, and so long as this is 
present, the tissue will react to massage and conges- 
tive hyperemia. These pathological structures can usu- 
ally be absorbed by conjestive hyperemia produced by 
constricting the base of the scrotum with the aid 
of an elastic band applied 3 to 12 hours daily. One 
or both testicles may be congested. 

The elastic band should be well padded as the loca- 
tion can not be changed and irritation of the under- 
lying skin is likely to occur. The constriction should 
be just tight enough not to feel uncomfortable. But at 
the same time, the underlying disease, the posterior 
urethritis and the vesiculitis must receive attention 
and appropriate treatment. For more detailed in- 
formation on this subject the reader is directed to 
Zabludowski's work on Technik der Massage, Leipzig, 
1903, and Bier's book, Hyperemia als Heilmittel, 
Leipzig, 1907. 

Gonorrheal orchitis without epididymitis occurs 
very seldom, and the subjective symptoms, the course, 
and the treatment are practically identical with those 
of epididymitis, which see. 



CHAPTER XIII. 

GONORRHEAL INFLAMMATIONS OF THE SEMINAL 

VESICLES. 

Inflammation of the seminal vesicles is usually accom- 
panied by prostatitis and posterior gonorrhea. Almost 
every symptom of vesiculitis can, under certain con- 
ditions, also appear in the affections just named. It 
is therefore almost impossible to make an absolute 
diagnosis. If pollutions form a prominent symptom, 
and if these are followed by a tired feeling and a depress- 
ing weakness, it may be taken as evidence of the in- 
volvement of the seminal vesicles. Although pain 
usually is not a prominent symptom of vesiculitis, some 
patients complain bitterly of disagreeable sensations 
and even severe pain, either immediately after the emis- 
sion or on the following day. Pain in the back and 
painful spasms at the neck of the bladder are common 
symptoms. The pollutions may be purulent or san- 
guineous in character, and the color may vary from a 
grayish-yellow to a chocolate-brown. 

The microscopic examination shows either no sper- 
matozoa at all, or only immotile ones, red corpuscles, 
ieucocytes and tissue debris. 

The treatment consists in curing the underlying dis- 
ease, the posterior urethritis and prostatitis, especially 

179 



180 TREATMENT OF GONORRHEA. 

the latter. Belfield* has obtained good results in the 
treatment of purulent affections of the seminal vesicles 
from irrigations and drainage of the seminal duct 
through the vas deferens. 

INFLAMMATIONS OF COWPER'S GLAND. 

This is a rare complication of gonorrhea, and ac- 
cording to English it is to be regarded as suspicious of 
tuberculosis. When it does occur it is manifested as a 
painful, usually unilateral swelling, below the bulb. 
The swelling may be so marked as to compress the 
urethra and cause urinary disturbances. 

The treatment of this condition consists in early in- 
cision and drainage. The abscess may rupture spon- 
taneously into the urethra and give rise to a slowly 
healing fistula. As a rule, however, it opens externally 
and heals without any further complications. In 
order to prevent urinary infiltration after the spon- 
taneous evacuation of the abscess into the urethra, it is 
well to keep a self-retaining catheter in the urethra 
for two or three days after the rupture has occurred. 

According to M. v. Zeissl, suppuration of Cow- 
per's gland is a frequent complication of croupous 
pneumonia. 

* Chicago Medical Recorder, No. n, 1906, p. 635. 



CHAPTER XIV. 
GONORRHEAL URETHRITIS IN THE FEMALE. 

Acute gonorrheal urethritis in the female is usually 
of short duration, and it may run its course without 
being detected by the patient. In the examination of 
prostitutes it is by no means infrequent to have massage 
of the urethra through the vagina produce a discharge of 
greenish-yellow pus, the patient not having any sub- 
jective symptoms. The symptoms usually become 
prominent only when the posterior portion of the ure- 
thra or the internal orifice and the trigonum are affected. 

For the protection of the patient, as well as that of 
her relations, sexual intercourse should be absolutely 
interdicted until the symptoms of infection have 
disappeared. 

As to the diet, the same rules hold good, as given 
under the chapter on gonorrhea in men. Warm douches 
of bichloride of mercury, i : iooo to i : 4000, should be 
given to the vulva several times a day; absorbent gauze 
containing iodoform or aristol should be put between 
the labia in the intervals. If pain and frequent urina- 
tion are present, they are best relieved by warm hip 
baths, given at a temperature of 95 to 105 , and hot or 
cold compresses applied to the region of the vulva and 
the os pubis in the intervals. 

The treatment of the urethritis proper is not as ur- 

13 181 



182 TREATMENT OF GONORRHEA. 

gent as in the male. The above-mentioned measures 
usually bring improvement, and even cure in a few 
days without any medical or instrumental treatment. 
The medical treatment consists in the internal admin- 
istration and local application of antiseptics. If the 
infection is a pure gonorrhea, the following prescrip- 
tion is of distinct value: 

1$ Olei santali ost indici, 

Ext. pichi Americi sicci, aa oij. 

Massae pil. q. s. ut fiant pilul, No. 60. (Kollmann.) 

If the infection is mixed, the following emulsion 
gives good service: 

]$ Copaibae , 3iv. 

Salol, 3iii. 

Mucilage acaciae, q. s., ad., 5iv. 

5j t. i. d. 

The local application of antiseptics is best done with 
a blunt-pointed syringe of two-dram size. 
As to prescriptions, see page 113. 
Ricord recommends the following mixture: 

1$ Zinc sulph., gr. x to xxx. 

Plumb, acet. bas. sol gr. xx to 5j. 

Tct. catechu, 



aa 5j. 

Tct. opu compos, ) J 

Aq. distill., q. s.. ad., Bxii. 

Inject three to four times a day. 

The introduction of iodoform, argyrol or protargol 
pencils is of little value. 

Kolischer has the pencils made without any wax 
because the latter substance is liable to produce con- 
cretions in the bladder. 



GONORRHEAL URETHRITIS IN THE FEMALE. 183 

The chronic gonorrheal urethritis does not necessar- 
ily manifest itself by distinct clinical symptoms. The 
diagnosis may, therefore, be dependent to a large ex- 
tent on the urethroscopic and cystoscopic findings. 
According to Kolischer, Oberlaender and Bumm, the 
chronic gonorrhea of the female urethra is represented 
by a soft infiltration only. Hard strictures producing 
infiltrations as we find them in men do not occur. The 
urethroscope shows, situated on the chronic inflamed 
mucosa, individual patches, round or oblong in shape, 
measuring about one centimeter in diameter. They 
have a velvety, swollen appearance. Their surfaces show 
granulations and small papillomatous excrescences which 
bleed easily when touched with the urethroscopic tube. 

The lips of the external urethral orifice often have a 
glassy look, and solitary follicular swellings and some- 
times little abscesses are found within their boundaries. 
Secretion cannot always be pressed out, even after long 
intervals of urination. In some cases we find hyper- 
trophic masses around and within the lips of the meatus. 
These structures were first described by Oberlaender. 
They are pathognomonic of gonorrhea, and are usually 
found only in prostitutes. In rare instances, accord- 
ing to Kollmann, they are found in the infected wife. 
They remain in the same condition for a long time, 
even after the gonorrhea has disappeared. 

The internal urethral orifice is often attacked by the 
gonorrheal infection and it then appears red and swol- 
len. The infected trigonum is also swollen and usually 
of a deep red color. 



184 TREATMENT OF GONORRHEA. 

The bladder must be emptied before the urethro- 
scopic tube is inserted, and tampons must be used freely 
after the tube is inserted, in order to prevent clouding 
of its surface by the steam forming around the lamp. 

Chronic affections of the urethra and bladder other 
than those of gonorrheal origin occur oftener in the 
female than in the male. The clinical symptoms are 
more uncertain in women than in men. Among the 
subjective symptoms may be mentioned tenesmus, 
pain on urination, a continuous sensation of burning at 
the external orifice, and a feeling of discomfort in the 
region of the bladder. Neither the intensity of the 
inflammation nor the severity of the pathologic proc- 
ess can be estimated by the prominence of the sub- 
jective symptoms. These seem to be more prominent 
during menstruation, when the diet is faulty, and when 
the patient is suffering from constipation. 

The progonsis is good in simple gonorrhea, but less 
favorable in the mixed infections. Malposition of the 
uterus often is the cause of a disturbance of the blad- 
der which may be diagnosed as gonorrhea. Slight ca- 
tarrhal conditions may be present, but the character- 
istic urethroscopic and cystoscopic findings are absent. 
A differential diagnosis is not always possible at first, 
and several examinations may have to be made. 

It must be borne in mind in this connection that 
gonorrhea and infections of the urethra which are 
believed to be gonorrheal extend more easily and 
oftener to the bladder, ureters, pelvis of the kidney 
and eventually to the kidneys themselves in the female 



GONORRHEAL URETHRITIS IN THE FEMALE. 185 

than in the male. Cystoscopic examination and ure- 
teral catheterization should be done in every suspicious 
case. 

The determination of the functional capacity of the 
kidneys may sometimes help to clear up an indefinite 
case. Furthermore, we must remember that the 
clinical symptoms of ureteritis and pyelitis often are 
not apparent. Our attention is directed to the disturb- 
ances on urination, and to various painful sensations 
in the region of the bladder, while an examination will 
disclose the urethra and bladder to be in a relatively 
healthy state or only slightly congested. The etiology 
and nature of such conditions is uncertain and puz- 
zling, especially if the disease has existed for years. 
Exacerbations of ureteritis and pyelitis are character- 
ized by the sudden appearance of turbid urine con- 
taining pus, and subjective symptoms pointing to in- 
volvement of the urethra and bladder. 

TREATMENT. 

Hexamethylenamin (urotropin) is very valuable in 
the mixed infections, but is absolutely without benefit in 
cases of simple gonorrhea. On the other hand, ni- 
trate of silver irrigations are particularly beneficial in 
simple gonorrhea, but they are not well borne in the 
mixed infections. Graduated dilatations are indicated 
both in the simple and mixed infections, if the urethro- 
scope reveals the changes in the mucosa that are typ- 
ical of chronic gonorrhea. 

A straight dilator with four branches is the most 



186 TREATMENT OF GONORRHEA. 

suitable for this purpose, unless some severe inflamma- 
tory condition of the meatus demands the use of an 
instrument of smaller size. The average number with 
which to start the dilatation may be given as 25 Char- 
riere. The use of a local anesthetic is recommended, 
at least at the beginning of the instrumental treatment. 
The dilatation should be stopped as soon as the 
patient complains of pain, and during the subsequent 
treatments the increase in the size of the instruments 
should be slow and careful. The reaction following each 
dilatation should be noted carefully. The meatus may 
be dilated up to 40 Charriere, if the dilatation is done 
gradually, and it is rarely necessary to go beyond that. 

Before the specimen of the urine is taken for examina- 
tion, it is best to irrigate the vagina first with a boric acid 
solution. Colonbacilluria is not a rare complication in 
these cases. The bowels should be regulated, and hexa- 
methylenamin (urotropin) may be given continuously. 

Relapses can be excluded in the female as little as in 
the male. The treatment must be discontinued during 
menstruation, and therefore the entire treatment con- 
sumes more time in the female than in the male. When 
the patient ceases to make satisfactory progress it is 
advisable to discontinue the treatment temporarily. 
It is often impossible to find a reason for this slow heal- 
ing. Sometimes the objective symptoms improve while 
the subjective symptoms remain almost stationary. 
Psychologic and hysteric influences must always be 
considered. 

The following rules must be observed when the in- 



GONORRHEAL URETHRITIS IN THE FEMALE. 187 

flammation has extended to the bladder, the ureters, 
or the pelvis of the kidneys. In ureteritis and pyelitis of 
gonorrheal origin, never fail to treat the underlying 
disease of the urethra and of the bladder. Only after 
this has been cured can we expect to arrest the process 
in the upper urinary organs. But the treatment must 
be mild. Any severe treatment, like rapid dilatations 
or frequently repeated irrigations with silver nitrate, 
must be avoided. Irritation of the lower urinary 
passages is referred reflexly to the upper diseased pas- 
sages. In certain cases instrumental treatment and 
even irrigations must be discontinued on account of 
this reflex irritation. 

The healing of the ureteritis and pyelitis is aided 
by the internal administration of hexamethylenamin 
(urotropin), oil of sandalwood, salosandal, and waters 
or teas, and by taking warm baths and hot half- 
baths. The diet should be regulated carefully, (see 
page in). The body should have good general care, 
and the patient should rest as much as possible. In 
affections of the bladder curved dilators should be 
used instead of the straight ones recommended for 
simple urethral affections. The irrigations should be 
copious and repeated often, and balsamics should be 
given internally. In cases where tuberculosis is sus- 
pected, it is best to discontinue instrumental treatment, 
and the severe irrigations. Irrigate with boric acid 
and by mouth give hexamethylenamin (urotropin) or 
guaiacol. Treat the patient as you would treat any 
cases of pulmonary tuberculosis. 



CHAPTER XV. 
GONORRHEAL METASTASIS. 

A number of diseased conditions in remote parts of 
the body result from the transmission of the gono- 
coccus by the lymph and blood circulation. The con- 
ditions are similar to those produced in pyemia and sep- 
ticemia. There may result an inflammation of a joint, 
of the heel, the iris, endocardium, meninges, muscles, 
tendons and their sheaths. These metastatic conditions 
may accompany chronic as well as acute gonorrhea. In 
most cases metastasis takes place during the second or 
third week of the disease. 

Gonorrheal arthritis is the metastasis that occurs 
most often. It is characteristic of this affection that it 
usually recurs with every new attack of gonorrhea and 
with every exacerbation of the old attack. It begins as 
an acute or subacute inflammation of one or more joints. 
The monoarticular form usually attacks the knee-joint. 
If the condition lasts for some time, it becomes chronic, 
is accompanied by a serous exudation, when it is 
called a gonorrheal knee. The polyarticular form 
gradually affects all the joints of the body. This form 
of arthritis is characterized by periarticular swelling 
and not infrequently it is accompanied by fever. 

Various joints are affected for varying periods of time. 
Any one joint may be attacked especially severely and 

188 



GONORRHEAL METASTASIS. 189 

be involved for a long time after the disease has sub- 
sided in all the other joints. In cases that run an un- 
favorable course, secondary contraction takes place in 
the capsule of the joint by reason of the newly-formed 
connective tissue. The mobility of the joint is reduced 
and sometimes ankylosis takes place. This is followed 
by atrophy of the muscles and the patient is rendered 
more or less helpless. 

Even in cases of long-standing, the prognosis is not 
absolutely bad, except when the case simulates an 
arthritis deformans. 

Besides the appropriate treatment of the original 
affection, the gonorrhea, the local treatment to be rec- 
ommended consists of the application of dry hot air, 
cataplasms and prolonged warm baths, and later on a 
well-conducted course of massage. 

Bier's method of treatment by means of a passive 
hyperemia also yields good results, especially in acute 
cases. The latter is the method to which I give pref- 
erence before all others. The most severe pains are 
often relieved within an hour after applying an elastic 
bandage, and we can at once begin with passive move- 
ments of the affected joint, and the splints can be 
left off, or only worn at night and in very severe 
cases. In order to secure good results by this method 
of treatment, the elastic bandage should be applied 
as high up as possible, and should be worn twenty to 
twenty-two hours out of the twenty-four. The con- 
striction must be strong enough to produce edema. 

Potassium iodide and sodium iodide, given in five 



190 



TREATMENT OF GONORRHEA. 



grain doses, three times a day, often produce benefi- 
cial results. 




Fig. 52. — Shows an elastic bandage applied for gonorrheal 
arthritis of the wrist. 



1$ Potassii iodidi, 5ijss. 

Elix. lacto pepsini, q. s., ad., Biv. 

S 3j t. i. d., p. c. 



GONORRHEAL METASTASIS. 191 

The following prescription has also given good 
service : 

1$ Aspirin, 3ii to iii. 

Urotropin, 3i to ii. 

Aquae, q. s., ad., giv. 

3i, three to four times a day. 

In cases in which rational medical and instrumental 
treatment cannot be given for the underlying infection, 
the gonorrhea, vaccination may benefit the patient, but 
the intoxication is seldom as specific as that derived 
from rational medical and instrumental treatment, and 
the results, therefore, are seldom as satisfactory. 



CHAPTER XVI. 
PERIURETHRAL INFLAMMATIONS. 

Inflammation of the periurethral tissues, the spongi- 
ous body of the urethra and the cavernous bodies of the 
penis, are of frequent occurrence in acute and in chronic 
gonorrhea. Cavernitis is due to the spreading of the 
gonorrheal or the mixed infection from the epithelial 
covering of the urethra through the mucosa and sub- 
mucosa to the corpus cavernosus urethrce, and in 
some cases to one or both of the cavernous bodies. 
These foci of inflammation usually disappear under 
appropriate treatment, but suppuration may occur. 
According to M. v. Zeissl, this takes place most often 
into the coronary sulcus near the frenulum. 

If the periurethral inflammation occurs during the 
course of an acute gonorrhea, very painful erections, 
called chordee, occur. Chordee is a curved erection of 
the penis with the concavity toward the focus of infil- 
tration. If there is present a cavernitis urethrae, the 
direction of the concavity is downward, and if the 
cavernous bodies are involved, the direction is upward. 
The forced curvation of the penis and the infiltration of 
the cavernous bodies may cause a tearing of the erectile 
tissues, and a consequent severe hemorrhage. 

If the foci of the acute infiltration are not com- 

192 



PERIURETHRAL INFLAMMATIONS. 193 

pletely absorbed, there remains an induration known as 
a chronic cavernitis, which may give rise to deformities 
of the penis. An etiologic relationship between such 
indurations and gonorrhea cannot alway be established. 
In some cases its discovery by the patient is coincident 
with the beginning of a secondary syphilis. The pa- 
tient will often give as a cause interrupted coitus. In 
most cases the induration has reached the size of a pea 
or larger before it is discovered by the patient. 

In the acute stage, the treatment should consist of 
absolute rest and the application of hot or cold and the 
use of mercurial salve. The treatment of the urethral 
gonorrhea is interrupted for the time-being. If fluctua- 
tion appears, the abscess should be opened and treated 
antiseptically. 

If the induration is a chronic one, it may be reduced 
by the use of galvanic electricity. The strength of the 
current necessary is six to eight milliamperes. The 
positive pole (sponge electrode) is saturated with iodide 
of potassium iodine solution and applied to the affected 
parts. The negative pole is applied either to the oppo- 
site side of the penis or intraurethrally. Complete ex- 
cision of the induration has also been recommended. 

The occurrence of such a complication during the 
course of instrumental treatment requires immediate 
cessation of the dilatations, and the institution of 
mild irrigations. The spontaneous evacuation of 
little abscesses should be waited for patiently. After 
the acute stage of the complication has passed, a grad- 
ual return to the instrumental treatment is indicated, 



i 9 4 TREATMENT OF GONORRHEA. 

inasmuch as the remains of the little abscesses are 
affected favorably by the graduated dilatations. 

The periurethral abscesses appear particularly dur- 
ing a chronic gonorrhea in which there exists a strong 
tendency toward the formation of strictures. The treat- 
ment consists in evacuation and drainage. The in- 
strumental treatment of the coexisting chronic gonor- 
rhea must be discontinued for the time-being. The 
remains of abscesses and even fistulae may be treated 
successfully by dilatation after the acute stage has 
passed. 

FOLLICULAR AND PERIURETHRAL ABSCESSES. 

The chronically inflamed follicles of the urethra 
appear as painless nodular swellings which are easily 
palpable when the urethra is distended with a hard in- 
strument. The size of these nodules varies from that 
of a lentil to that of a pea. No special treatment of 
these swellings is indicated unless they become very 
large and painful, an incident which may occur inde- 
pendently of any treatment that may be given. 

PARAURETHRAL DUCTS. 

Formerly, these ducts were regarded as structures of 
minor importance, and only during the past few years 
have they come into any prominence at all in connec- 
tion with the treatment of gonorrheal affections of the 
urethra. They are invaded easily by the gonococcus, 
but on account of their anatomic condition, it is diffi- 
cult to treat them. These ducts, unless recognized 



PERIURETHRAL INFLAMMATIONS. 195 

by the operator, may be the seat of most obstinate 
infections. 

Treatment. — The ducts are split open as far back 
as possible and are treated by the application of com- 
presses of acetate of aluminum or with moist or dry 
iodoform or aristol gauze, or iodoform collodion. In 
the case of ducts situated in the region of the prepuce, 
and that have a straight course, good results may be 
obtained from electrical acupuncture. The direction of 
the duct may be ascertained with a thin round wire, and 
the narrowest parts may be widened somewhat. The 
negative electric sound is then introduced to the end of 
the duct, the positive pole being applied to the opposite 
side of the penis. The strength of the current is meas- 
ured by the sensations of the patient. It should be 
strong enough to cause a slight prickling pain. Bleed- 
ing should be avoided as much as possible. 

The repair of the tissues after electrolytic interven- 
tion will require from fourteen days to three weeks. 
The treatment may have to be repeated a number of 
times before satisfactory results are obtained. The 
ducts may also be irrigated or injected with a 2 to 5 
per cent, solution of silver nitrate. A blunt canula is 
used to make the injection. 



CHAPTER XVII. 
HEMORRHAGE. 

Hemorrhages take place in the course of the treat- 
ment of gonorrheal affections, either spontaneously or 
as the result of therapeutic intervention. When the 
hemorrhage is in the anterior urethra bleeding will 
take place in drops, or the blood will coagulate around 
the meatus. If the hemorrhage is in the posterior 
urethra, the blood may drop from the meatus after 
urination, or if the bleeding is slight, the last drops 
of urine only are blood-stained or the blood may flow 
into the bladder in smaller or larger quantities to be 
mixed with the urine or to settle to the bottom, ap- 
pearing as a sediment at the end of urination. 

The hemorrhages from the sexual glands are by far 
the most common. The blood flows into the bladder 
and is voided with the urine. Hemorrhages in the 
seminal vesicles, spermatic cord, the epididymis, or 
the testes, are manifested by coffee-brown seminal 
emissions. Bleeding from the ejaculatory ducts pro- 
duces an admixture of fresh blood with the sem- 
inal discharge. Bleeding of the mucosa of the bladder 
and hemorrhage from the upper urinary passages very 
seldom is caused by the gonorrhea. Such a hemor- 
rhage must always excite suspicion of the presence of 

196 



HEMORRHAGE. 197 

other disease conditions, such as tuberculosis, tumors, 
or concretions. 

It is not always easy to determine the seat of the 
hemorrhage. Even the most experienced operator may 
be in error, especially when the decision must rest be- 
tween bleeding in the posterior urethra and bleeding in 
the bladder. Hemorrhages from the urethra may take 
place spontaneously, that is, they are caused by the 
disease alone, or they may be the consequence of 
trauma of the mucous membrane of the urethra inci- 
dent to the treatment, such as the introduction of an 
instrument or the local use of caustic drugs. Spon- 
taneous bleeding of the anterior urethra occurs much 
less often than from the posterior urethra. This is 
easily understood when we take into consideration 
the fact that the mucous membrane of the posterior 
urethra is of a more delicate structure than that of the 
anterior urethra, and that the underlying tissues in the 
posterior urethra are less elastic and therefore more ex- 
posed to insult than those of the anterior urethra. 

Spontaneous bleeding of the anterior urethra occurs 
during the course of a chronic gonorrhea, especially 
after sexual intercourse, and is usually caused by 
epithelial granulations or by papillomata. A care- 
ful urethroscopic examination will always reveal the 
cause of and locate the bleeding. Oberlaender ob- 
served two cases where the bleeding occurred after 
coitus and was caused by infiltrations of the second 
degree that were located in the bulb. In one case the 

bleeding had lasted three weeks, and the patient had 
14 



198 TREATMENT OF GONORRHEA. 

become anemic. In the other case the bleeding had 
existed only eight days. In both cases the hemorrhage 
ceased after the first dilatation. 

Bleeding from the posterior urethra usually shows 
itself as a so-calld terminal bleeding (Posner). It 
may last days or weeks, with or without intermission, 
and with the loss of varying amounts of blood. If 
the blood flows into the bladder and is voided with 
urine it may be mistaken for a case of hemorrhage from 
the bladder. A careful urethroscopic examination 
of the posterior urethra will usually locate the bleeding 
points, whereas cystoscopy is negative. 

Papillomata are often found to be the cause of bleed- 
ing. Forced dilatation should be carefully avoided in 
such cases. If the terminal bleeding persists after mic- 
turition, and if there is no history of gonorrhea, and if 
the objective findings are negative of gonorrhea, the 
case should excite suspicion, and tuberculosis should 
be thought of. This doubt must be cleared up before 
instrumental treatment is proceeded with. 

The treatment of hemorrhages consists of rest, ice 
compresses, and eventually the introduction of a per- 
manent catheter. 



CHAPTER XVIII. 
THE VACCINATION THERAPY OF GONORRHEA. 

The methods of treatment described in the previous 
chapters deal with the destruction of the infecting germ 
by local chemical and local hyperemic means. The 
vaccination therapy of gonorrhea tends to increase the 
resistance of the patient, and thus promote the destruc- 
tion of the gonococcus by anti-bodies and essential 
phagocytosis. 

The method consists in the subcutaneous injection 
of measured doses of killed gonococci, or in case of a 
non-specific or a mixed infection of the urethra, of the 
germs found in the discharged pus, to which the 
patient's serum shows a low opsonic index. The mi- 
croorganisms to be used for vaccination are cultivated, 
their number approximately determined, and then 
sterilized at 6o° Celsius. The quantity of vaccine to 
be used is determined by the effect which an injection 
has upon the opsonic index of the patient. 

If a suitable dose has been given, there occurs a 
short negative phase — the anti-bodies and the opsonins 
are decreased in quantity, and this is followed by a 
rather prolonged positive phase, anti-bodies and opso- 
nins are increased. 

If too large doses are given, the negative phase is 
exaggerated and prolonged. 

199 



200 TREATMENT OF GONORRHEA. 

It has been noted that improvement and even recov- 
ery go hand in hand with the increase of the opsonic 
index. But the majority of these investigations have 
been made with more enthusiasm than truly scientific 
spirit and special knowledge, and the results of their 
experiments do not stand scientific criticism. 

The opsonic index of the patient's serum is deter- 
mined by Wright's method, but its technic is disagree- 
able to the patient, and only few — mostly old, obsti- 
nate, mixed infections can be induced to stand the 
ordeal of a course of treatment controlled by the 
opsonic test. Experiments which have been going on 
for some time at the Columbus Medical Laboratories 
show that the therapeutic results obtained by the vac- 
cination therapy are a valuable addition to the medical 
and instrumental treatment. 

But the vaccination therapy as well as the medical 
and the instrumental treatment are limited to the 
production of injuries, and as the injury intended for the 
disease-producing germ will equally affect its host, the 
therapeutic results, good or bad, will depend upon the 
resistance and recuperative power of the patient. In 
other words, we have only one curative agent, only one 
remedy, namely, the patient. 

The human body is the product of the struggle for 
existence, a selected fighter, who has learned to convert 
received injuries into stimuli of his own defense. The 
specific injury, the specific intoxication, which is ob- 
tained from the indirect action of the medical and the 
instrumental treatment, and under favorable conditions 



VACCINATION THERAPY OF GONORRHEA. 201 

also from the vaccination, will, if adequately measured, 
stimulate the curative forces of the body to an increased 
effort at the defense. 

I have at present under observation three cases of 
gonorrhea and gonorrheal arthritis, which have been 
greatly improved by local medical and instrumental 
treatment, while several courses of vaccine and serum 
treatment were without benefit to the patients. 



INDEX. 



Abscesses, follicular, 19, 194 

of Cowper's gland, 180 

of the prostate, 162 

periurethral, 18, 194 
Abnormal secretion, 159 
Absence of gonococci, 17 
Accelerator urinae, 7 
Acetate of zinc, 113 
Acid, nitric, 98, 113 

resinous, 93 
Activity, chemical, 95 
Acute epididymitis, 173 
Acute gonorrhea, 14, 42, 107 
Adnexa, 132, 139 
Agar, human blood serum, 13 
Albuminuria, 164 
Alcoholism, 68 
Alkalies, 164 
Alum crudi, 113 
American scala, 85 
Amyloid corpuscles, 160 
Anatomical obstructions, 144 
Anatomy of the urethra, 1 
Anilin dyes, n 
Anilin oil, 12 

Anilin water gentian violet, 12 
Anion, 97 
An ti -bodies, 199 
Antigonorrheal serum, 191 
Antiseptics, action of, 93 



Appearance of ejaculatory ducts, 

40 
Argyrosis, 64 
Argyrol, 95 

Argyrotic discolorations, 40 
Arhovin, 95 
Astringent action, 97 
Arthritis, gonorrheal, 188 
Artificial eczema, 177 
Aspirin, 94, 191 
Atony of bladder, 47 

Bacillus, cholera, 13 

pyocyaneus, 13 

typhosus, 13 
Bacteriuria, 155 
Balsam, Canada, 12 

copaibse, 94 
Belfield, 180 
Bicyclists, 157 
Bier, 178 

Bier's method, 189 
Bismarck brown, n 
Bladder, atony of, 47 

catarrh of, 148 

Cadaver, 61 
Callosities, 19 
Catheters, 35, 70, 144 
Cauterization, 136 



203 



204 



INDEX. 



Cavernous spaces, 19 
Cavernous urethra, 8 
Central field, 37, 50, 133 
Changes in the epithelium, 62 
Charriere, 85 
Charriere scale, 28 
Chemically inert silver, 96 
Chordee, 192 

Chronic gonorrhea, 17, 162 
Chronic epididymitis, 177 
Chronic nephritis, 148 
Cocaine suppositories, 151 
Coitus, 69 

interrupted, 193 
Colonbacilluria, 155, 186 
Colliculus seminalis, 19, 32, 40 
Colloid material, 44 
Commissura prostatica, 5 
Complications of gonorrhea, 157 
Compresses, hot, 112 
Compressor urethrae, 7 
Concretions, 197 
Congenital diverticulum, 39 
Congestive hyperemia, 92, 189 
Corium, 18 
Cowper's gland, 8 

abscess of, 180 
Crypts of Morgagni, 8, 18, 46 
Cultures, 143 
Curette, 34 

Curves, Dittel and Guyon, 70, 132 
Cysts, 18 
Cystoscope, 41, 137, 185 

Daily irrigations, 117 
Depression, mental, 161 
Determination of functional ca- 
pacity of kidneys, 185 



Determination of the source 

of secretion, 124 
Diagnosis of collasities, 151 

of epididymitis, 173 

of gonorrhea, 27 

of hard infiltrations, 50 

of hemorrhage, 196 

of prostatitis, 158 

of soft infiltrations, 45 

of vesiculitis, 179 
Diagnostic irrigations, 23 
Diet, in, 186 
Digestive tract, 161 
Dilatations, 104, 118, 167, 185 
Dilators, 70, 78, 80, 127, 147 
Dissociation, 95 
Disturbances on urination, 153, 

185 
Dittel, 72 
Dittel's curve, 166 

endourethral forceps, 154 

prostatic sinus, 24, 90 

Eczema, 176 

Edema, 99 

Elastic sounds (bougies), 84 

Endarteritis, 15 

Endoscopic knife, 136 

English, 180 

English measurements, 85 

Ejaculatory duct, 1, 160 

Epididymitis, no, 162, 171, 175 

Epithelium, changes of, 62 

Erectile tissue, 19 

Experimental gonorrhea, 13 

Fatigue, instrumental, 148 
of the limbs, 161 



INDEX. 



205 



Feleki, 170 

Fermented drinks, 11 1 

Filaments, 138, 163, 167 

Filiform bougie, 25 

Finger, 16 

Fistulae, 18, 194 

Five glass test, 119 

Folds, longitudinal and transverse, 

37 
Fossa navicularis, 15 
Frank, 6 
Frenulum, 192 

Galvano-cautery, 154 
General consideration of treat- 
ment, 92 
Germicidal preparations, 96 
Gland, prostate, 4, 157 

Cowper's, 8, 180 

Littre's, 8, 19, 46 
Glass tests, 21 
Globules, hyaline, 167 
Glycerine, 31 
Goldberg, 23, 157 
Goldschmidt, 32 
Gonococcus, 10, 98 
Gonorrhea, acute, 14, 42, 59, 107 

chronic, 17, 113 

complications, 68 

diagnosis of, 21 

pathology of, 10 

prognosis of, 66 

treatment of the stages of, 107 

varieties of, 42 
Gonorrheal arthritis, 188 

epididymitis, 173 

metastasis, 188 

prostatitis, 157 



Gonorrheal urethritis of the fe 
male, 181 

vesiculitis, 179 
Graduated dilatations, 103, 126 
Gram solution, 12 
Gruenfeld cold wire snare, 154 
Guebler, n 
Guyon -Thompson stone-searcher, 

70 
Guyon's curve, 166 
Guyon's deep injections, 99 

drop syringe, 36 

explorator, 24, 74, 83 

Hard infiltrations, 42 

first degree, 50 

second degree, 54 

third degree, 57 
Heel, 188 
Helmitol, 94 
Hemorrhage, 196 
Hemorrhoidal nodes, 169 
Henle, 7 
Heynemann, 29 
Human blood serum agar, 13 
Hypertrophic masses, 183 

Ichthyol injections, 113, 172 
Immunity, 14, 157 
Incandescent lamp, 29 
Incisura prostatica, 5 
Induration of the head of the 

epididymis, 177 
Infection of prostate, 120, 157 
of seminal vesicles, 120, 179 
Infiltration of the colliculus, 61 
Injections, no, 118 
Injector, 73 



206 



INDEX, 



Inorganic salts, 96 
Instillator, 73 

Intraurethral galvanization, 135 
Intravesicular portion of the ure- 
thra, 2, 121 
Instrumental examination, 24 

treatment, 103 
Intoxication, 165 
Ionizing solvent, 96 
Ions, 96 

Irrigation, 102, 187 
Irrigating catheter, Oberlaender's, 

72 
Irrigating dilators, 115, 129 

Jadassohn, 22 
Joung, 23 

Kalischer, 5, 7 
Keyes, 85 

Knee obturator, 34 
Kolischer, 183 

Kollmann, 28, 29, 42, 105, 106, 
i39> J 49, 182 

Lacuna magna, 8 

Langley, 6 

Lecithin, granules, 160 

Ligamentum triangulare urethrae, 

8 
Lichtenberg, 8 
Light-carrier, 30 
Lithotomy position, 32 
Loeffler's alkaline methylene blue, 

i°> 13 
Lohnstein, 81, 105 

Lubricants, 91 
Massage, 169 



Masturbators, 157 
Meatotomy, 31, 130 
Meatus urinarius, 8, 21, 31 
Medical treatment, 93 
Membranous urethra, 6 
Methylene blue, 10, 13 
Milking of prostate, 119 

Nature, 92 

Navicular fossa, 87 

Neelson, 44, 106 

Neisser, 10 

Neurasthenia, 68 

Neurasthenics, 114 

Nitrate of silver, 64, 99, 102, 117 

Nitric acid, 98, 102, 113 

Nitze, 28 

Non-gonorrheal urethritis, 155 

Oberlaender, 28, S3, 35, 42, 105, 
106, 133, 139, 152, 153, 

158, 183 

Oberlaender's meatotome, 31 

Obturator, 28, 34 

Oil of sandalwood, 93 

Opalescent spots of pachyder- 
mia 5I 

Opsonic index, 69, 199 

Pain on urination, 126 
Palpitation, 21, 158 
Papillomata, 18, 154 
Papillomatous excrescences, 183 

urethritis, 152 
Paraurethral duct, 194 
Pendulous urethra, 56, 57 
Periarteritis, 15 

Perineal incision, pre-rectal, 165 
Periurethral abscesses, 18, 194 



INDEX. 



207 



Periurethral inflammation, 192 

Phagocytosis, 199 

Phase, negative and positive, 199 

Phosphate of calcium, 163 

Phosphaturia, 163 

Physiological salt solution, 159 

Piles, 162 

Pledgets of cotton, 153 

Pollutions, 179 

Posterior urethritis, 138, 166 

Potassium permanganate, 102, 117 

Precipitation, 96 

Premature ejaculation, 161 

Prognosis of gonorrhea, 66 

of prostatitis, 164 
Prostate, abscess of, 162 

lobes of, 5 
Prostatic ducts, 5, 137 
Prostatitis, 20, 157 
Prostatorrhea, 168 
Psoriasis mucosae, 64 
Psychrophore, 171 
Purulent secretion, 138 
Pyelitis, 187 
Pyuria, 155, 166 

Reaction, 147 
Record, 124 

Region of seminal vesicles, 172 
Reichmann, 156 
Reinfection, 123 
Relapses, 56, 67, 123, 129 
Reliquet, 6 
Residual urine, 164 
Resorcin, 64, 154 
Retention of urine, 148 
Rogers and Torry, 191 
Rudinger, 5 



Scharff, 172 
Schlagintweit, 159 
Scrotum, 175 
Seminal vesicles, 160, 170 
Senile hypertrophy, 164 
Septicemia, 155 
Sexual glands, 32 

impotence, 161, 169 
Silver nitrate, 64, 95, 99, 102, 117 
Sinus pocularis, 39 
Smegma-like substance, 152 
Soft infiltrations, 42, 45, 47, 49, 

Spatulum, 34 

Special treatment of anterior ure- 
thra, 130 

posterior urethra, 137 
Spermatic cord, 162 
Spermatic crystals, 160 
Spermatozoa, 160 
Spermatorrhea, 137, 168, 174 
Sphincter tonus, 5 

urethras membranacea, 7, 16 

vesicae, 5 
externus, 7 
triagonalis, 6 
Staphylococcus, 65, 128 
Sterile glycerine, 31 
Straight sounds, 127 
Strangury, 112 
Stream, 142 
Streptococci, 165 
Stricture, 57, 142, 145 

of wide caliber, 43 

scarry,- 61 
Subcutaneous injection, 199 
Sulcus caronarius, 37 
Sulphate of zinc, 102 



208 



INDEX. 



Suppuration, 92 
Surgical intervention, 146 
Symphysis pubis, 5, 161 
Symptom-complex, 161 
Syphilis, 193 
Systemic reaction, 128 

Tampons, 153, 184 

Temperature optimum, 13 

Tenesmus, 145 
on urination, 121 

Terminal bleeding, 198 

Thompson's two glass test, 22 

Toureux, 4 

Transitory increase in clinical 
symptoms, 104 

Transparent vesicles, 54 

Treatment, general considera- 
tion of, 92 
medical, 93 
local, 100 
instrumental, 103 
of acute gonorrhea, 107 
of chronic gonorrhea, 113 
of epididymitis, 175 
of gonorrheal arthritis, 189 
of gonorrhea in female, 185 
of hard infiltrations, 122 
of hemorrhages, 198 
of non-gonorrheal urethritis, 

150 
of papillomatous urethritis, 153 



Treatment of prostatitis, 165 

of soft infiltrations, 114 
Trigonum vesicae, 3 
Tuberculosis, 164, 197 
Tumors, 197 
Two glass test, 22, 143 

Ureteritis, 185 
Ureters, 184 
Urethra, length of, 1 
Urethritis mucosae, 45 
sicca proliferans, 53 
Urethroscopic examination, 113, 

tube, 28 
Urinary antiseptics, 165 

bladder, 2 

sediments, 47 
Urogenital sinus, 1 

Vaccination therapy of gonorrhea, 

199-201 
Valentine, 29, 109 
Varieties of gonorrhea, 42 

Walsch, 155 
Wertheim, 13 
Winternitz, 168 

Zeissl, 6 

Zinc sulphate, 102 

Zuckerkandl, 6 



(3) 






1310 



One copy del. to Cat. Div. 



